Every finding on record at Field Crest Care Center

Based on observation, interview and document review, the facility failed to ensure an oxygen tank was handled safely for 1 of 1 resident (R24) reviewed for safety hazards.Findings include: R24's face sheet printed on 2/18/26, included diagnosis of chronic obstructive pulmonary disease (COPD, a lung disease making it difficult to breathe).R24's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, clear speech, could understand and be understood. R24 required supervision or partial assistance with activities of daily living. R24 used oxygen. R24's physician orders dated 2/4/26, indicated room air - 2 lpm (liters per minute) oxygen via NC (nasal cannula) with exercise/activity to maintain oxygen saturation greater than 88%. R24's care plan with revised date of 2/11/26, indicated the resident had COPD. Oxygen settings: Room air - 2 LPM O2 via NC with exercise/activity - attempt to titrate to room air to maintain oxygen saturations greater than 88%. During an observation on 2/18/26 at 8:00 a.m., an E-size oxygen tank was observed standing unsecured in the hallway outside of the beauty shop. There had been oxygen tubing draped on it. During an interview on 2/18/26 at 8:02 a.m., nursing assistant (NA)-A stated the tank belonged to a resident who was in the beauty salon getting her hair done. NA-A did not know if the tank standing unsecured posed a safety risk. NA-A did not recall specific training on oxygen tank safety. During an interview on 2/18/26 at 8:05 a.m., NA-B approached the tank and said she had asked a nurse about it who said it can't be left unsecured as it created a trip hazard and if knocked over, could explode. NA-B stated she had received oxygen safety training. NA-B stated the beautician had removed the tank from the cart and put it in the hallway. During an interview on 2/18/26 at 8:06 a.m., NA-C brought an oxygen tank hand cart and placed the tank into the cart. NA-C stated an unsecured oxygen tank was a safety risk because the tank could fall over and explode. During an interview on 2/18/26 at 8:14 a.m., beautician (B)-B, stated she did not remove the oxygen tank from R24's wheelchair and place it in the hallway. B-B stated she was aware oxygen could not be used in the salon, but it would not be up to her to remove a tank from a resident. During an interview on 2/18/26, at 10:15 a.m., NA-A stated she had removed the oxygen tank from R24's wheelchair after escorting R24 to the beauty salon, and had placed the tank in the hallway, unsecured. NA-A stated she was now aware oxygen tanks needed to be placed in a cart and not left standing unsecured.During an interview on 2/18/26 at 12:30 p.m., the co-executive director (CED)-A who was also director of social services, stated she had been made aware of the unsecured oxygen tank by staff and would have expected staff to adhere to safe practices per policy. CED-A provided a policy titled Oxygen Storage, Maintenance, Handling and Use dated 1/27/18, which NA-A had signed off on, on 11/6/18 as part of oxygen safety training. The policy indicated oxygen cylinders would be stored in racks with chains, sturdy portable carts, or approved stands. Oxygen cylinders would never be left free-standing.Facility Oxygen Storage, Maintenance, Handling and Use policy dated 1/16/26, indicated oxygen cylinders would be stored in racks with chains, sturdy portable carts, or approved stands. Oxygen cylinders would never be left free-standing.

Based on observation, interview and document review, the facility failed to ensure personal protective equipment (PPE) was implemented to prevent the spread of Covid19 per guidance by the Centers for Disease Control (CDC), when during a Covid19 outbreak, residents were observed not wearing masks. This had the potential to effect all 30 residents who resided in the facility. Further, the facility's failed to have an adequate water management program. The facility's water management program was incomplete and was not consistent with current ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Guideline, which specifically called for design and maintenance procedures for the potential exposure of Legionnaire's disease (a serious pneumonia infection) within a healthcare facility. This had the potential to effect all 30 resident who resided in the facility to be infected by Legionella. Findings include: During an observation on 12/5/22, at 3:04 p.m., 11 residents and one visitor were playing bingo in the dining room at three tables. Only the visitor was masked. Nursing assistant (NA)-A identified the residents: ---One table had five unmasked residents: R1, R25, R22, R2, R23. ---One table had three residents and one visitor: R18's mask was below nose, R4's mask below mouth, R15 no mask, and visitor was masked. ---One table with three unmasked residents: R179, R19 and R12. During an interview on 12/6/22, at 9:02 a.m., nursing assistant (NA)-B stated residents were asked before they left their rooms if they wanted to wear a mask, adding residents had a right to refuse. Together with NA-B, looked at NA documentation in the electronic medical record (EMR). Every shift, NA's where to document two tasks related to resident masking: 1) Ask resident to apply mask when completing cares and 2) Ask resident to apply mask when leaving their room. NA's were to answer if the task was completed. For the past two weeks, some NA's answered the question yes, and some answered no. NA-B stated no meant the resident declined the mask. NA-B stated some staff maybe did not understand the question and documented no, meaning they did not ask the resident to apply a mask. During an interview on 12/6/22, at 9:03 a.m., (NA)-C stated NA's were to ask residents if they wanted to put on a mask before they left their room, adding, But do we always? No. NA-C stated she did not always remember to ask a resident. NA-C was aware the facility was currently in Covid19 outbreak status. During an interview on 12/6/22, at 9:05 a.m., registered nurse (RN)-D stated staff encouraged residents to put on a mask when done with resident cares and before residents left their room, adding they supplied each resident with a new mask each day. Together looked at the EMR and NA tasks. RN-D verified sometimes the task was completed and sometimes it wasn't. NA-A stated the expectation was that staff would offer a mask to a resident before leaving their room, but some residents would decline and had a right to do so. During an interview on 12/7/22, at 9:28 a.m., R2 (who was cognitively intact per quarterly Minimum Data Set [MDS] assessment dated [DATE]), was sitting in a wheelchair in her room watching TV. R2 stated staff sometimes asked if she wanted to wear a mask, but not always. R2 stated if staff reminded her, she wore a mask .If they don't remind me, I don't remember. R2 stated she was aware of Covid19 and wearing a mask helped prevent catching it. During an interview on 12/7/22, at 9:35 a.m., R25 (who had moderate cognitive impairment per admission MDS dated [DATE]), in her room, stated staff did not ask her if she wanted to wear a mask when she left her room. Looked around for a mask, stating she didn't see one and stated it might be in a drawer somewhere. During an interview and observation on 12/7/22, at 9:37 a.m., observed (NA)-C transport R17 via wheelchair out of her room to the dining room. R17 was not masked. NA-C admitted he did not ask R17 if she wanted to mask before leaving her room, adding, I should have, but I didn't; they almost always say no. Observed R17 and R19 sitting together in the dining room, both unmasked. During an interview on 12/7/22, at 9:47 a.m., R17 (who was cognitively intact per admission MDS dated [DATE]), stated staff did not ask her if she wanted to wear a mask when she left her room. R17 stated she knew she should wear a mask, but it fogged up her glasses if they could find a mask that didn't fog up my glasses, I would [wear one], adding she knew it was important as she used to work in healthcare and wore a mask all the time. During an interview on 12/7/22, at 12:20 p.m., R23 (who had moderate cognitive impairment per quarterly MDS dated [DATE]), in her room watching TV. Stated no one asked if she wanted to wear a mask when she left her room, adding she would wear one if asked, as it was better to err on the side of caution. Observed two masks in R23's room; neither appeared to have been wore, both flat and unwrinkled. During record review of residents observed unmasked in communal areas: --R18, R4, R179, R19, R17: Nothing in care plan about Covid19 and nothing about masking. --R15's care plan dated 5/6/22: Focus of Covid19 was present; nothing about masking. --R12's care plan dated 5/18/20: Focus of Covid19 was present; nothing about masking. During an interview on 12/7/22, at 10:56 a.m., with administrator, RN-D, (RN)-B and SW-A, all verified the Covid19 community transmission rate was high and the facility was in Covid19 outbreak status. Informed of observations of residents not wearing masks. RN-B stated residents were asked to mask before leaving their rooms. RN-D stated most residents chose not to wear a mask. During the same interview, RN-B stated she was responsible for creating and updating care plans and that Covid19 language in care plans was standard. RN-B stated some residents didn't have Covid19 language in their care plans as she had not gotten to some of the newer residents yet. RN-B confirmed the Covid19 language in the care plan did not indicate anything about resident masking; whether they should wear masks or if were unable to tolerate wearing a mask. RN-B acknowledged she was aware during a Covid19 outbreak, everyone should mask in communal areas. The administrator stated residents had been educated about wearing masks, but it had been awhile, and stated there was likely some mask fatigue among residents. The group acknowledged Covid 19 was still a concern and it was important to ensure residents were protected. During an observation on 12/7/22, at 12:10 p.m., observed an unidentified staff member in the dining room asking residents, Do you want to put a mask on? The question did not included rationale for asking. During an interview on 12/7/22, at 1:32 p.m., the administrator stated since meeting earlier, staff had been asking residents if they wanted to wear a mask and residents had been saying no. Informed the administrator that this was observed in the dining room and that the question was asked without telling the resident why and was likely an ineffective way to encourage residents to wear a mask during an outbreak. The administrator was encouraged to consider a reset with residents and staff and reeducate on the rationale for wearing masks. Facility policy titled Source masking for residents, revised date of 3/24/22, indicated the purpose was to minimize the threat of Covid19 transmission. A surgical mask would be provided to all residents daily upon request. Residents would be educated on the use of masks. Resdient's have a right to refuse to wear a mask at any time, even during outbreak status. 12679 Water management program Review of website for ASHRAE titled Risk Management For Legionellosis dated 10/15 indicated . The design engineer first needs to evaluate which requirements of the standard apply to their project. This evaluation determines if the project contains any of the following building risk factors. Health-care facility with patient stays over 24 hours. Facilities designated for housing occupants over age 65. The risk of disease or illness from exposure to Legionella bacteria is not as simple as the bacteria being present in a water system. Other factors that contribute to the risk are environmental conditions that promote the growth and amplification of the bacteria in the system, a means of transmitting this bacteria (via water aerosols generated by the system), and the ultimate exposure of susceptible persons to the colonized water that is inhaled or aspirated by the host providing a pathway to the lungs. The bacteria are not transmitted person-to-person, or from normal ingestion of water. Susceptible persons at high risk for legionellosis include, among others, the elderly, dialysis patients, persons who smoke, and persons with medical conditions that weaken the immune system Review of the Centers for Disease Control and Prevention (CDC) website titled Legionella. Prevention and Control, dated 03/25/21 indicated .The key to preventing Legionnaires' disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella.Key Elements.Seven key elements of a Legionella water management program are to. Establish a water management program team. Describe the building water systems using text and flow diagrams. Identify areas where Legionella could grow and spread. Decide where control measures should be applied and how to monitor them. Establish ways to intervene when control limits are not met . Make sure the program is running as designed (verification) and is effective (validation).Document and communicate all the activities. Principles. In general, the principles of effective water management include.Maintaining water temperatures outside the ideal range for Legionella growth.Preventing water stagnation.Ensuring adequate disinfection.Maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella.Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met. Review of a document provided by the facility titled Legionella Water Management Program, dated 06/02/17 indicated .It is the policy of Fairview Care Center to prevent an outbreak of Legionnaires Disease through implementation of an effective Legionella Water Management Program.Preventative Maintenance.Faucet aerators will be replaced every two years.Shower heads and nozzles will be replaced every two years.Eyewash stations bottles will be replaced per manufacturer's recommendation/expiration date.Quarterly water samples from 10 risk locations throughout the facility will be tested . Sample must be collected from a temperature range of 50-104 degrees Fahrenheit.Results will be compared to the normal range.Results will be recorded in the Logbook.Positive results require additional testing with 5 business days. Review of a binder provided by the facility titled Water Management Program included facility policies on their water management program, a Legionella testing log which had five testing entries dated 10/21 (there was no year documented). Included was test for Legionnaire's disease dated 03/14/18 which indicated the test results were within acceptable levels. There was a description of the water lines and how the water was processed throughout the facility and then sent out and then sent to the facility's sewer. Included was a hand drawn diagram of the facility's water system. Included was an uncompleted CDC risk assessment for the prevention of Legionella. During an interview on 12/05/22 at 4:29 p.m., the maintenance director-(MD)-A stated he was hired in September of 2019 and was to be trained on how to implement the water testing for Legionella, but this never happened. The MD-A stated the water management program was never fully implemented. MD-A stated he changes the faucets aerators every two years. MD-A stated there had been only one test for Legionnaires completed and that was in 2019. During an interview on 12/05/22 at 7:13 p.m., the director of nursing (DON) stated there had not been any Legionella in the facility for the past three years. During a subsequent interview on 12/06/22 at 8:46 a.m., MD-A stated when he took over the maintenance position he was in the dark about Legionella. MD-A stated the date of the testing logs was 10/21/19 and this was the last time a Legionella test was completed. MD-A confirmed there were no additional testing logs besides the ones from 10/21/19. MD-A stated there has been no annual review of the water management program. MD-A stated he contacted the former Administrator for direction. MD-A stated he planned on reaching out to a company who could develop and perform the requirements for an effective water management program. During an interview on 12/06/22 at 9:23 a.m., MD-A stated the city water utility company completed water testing each week but did not know the results. MD-A stated there has been no integration with the city utility company and the facility's water management program. MD-A stated he did not complete logs of when faucets, shower heads pipes, or the ice machine were maintained. During an interview 12/06/22 10:36 a.m., the DON stated the city water utility company tested for chlorine and fluoride. The DON provided these documents, from the city, for verification. During an interview on 12/06/22 at 11:22 a.m., the Clinical Manager/Infection Control Preventionist (CM/ICP)-B stated she did not get involved in the facility's water management program. CM/ICP-B stated if a resident tested positive for Legionella, she would notify the local health department and receive direction. CM/ICP-B stated she did not get involved with environmental issues and potential outbreaks of Legionella. During an interview on 12/06/22 at 2:50 p.m., the DON confirmed there were 30 residents over the age of 65. DON stated 10 of these residents had respiratory disease and three used a continuous positive airway pressure (CPAP) machine. During an interview on 12/07/22 at 8:26 a.m., the administrator stated her expectation was to have an effective water management program. .

Based on observation, interview and document review, the facility failed to ensure required and accurate nursing staffing information was posted for residents and visitors. This had the potential to affect all 30 residents residing in the facility and their visitors. Findings include: The nursing staffing posting was observed in an acrylic wall pocket between resident hallways and near the dining room. The document was titled Today's Staffing and indicated the following: --Name of facility --Department of Nursing --Date --Census --Shift start times --Number of RN (registered nurse) hours and FTE's (full time equivalents) for the day, evening, and night shifts. --Number of LVN (licensed vocational nurse)/LPN (licensed practical nurse) hours and FTE's for the day, evening, and night shifts. --Number of Assistants/Techs hours and FTE's for the day, evening, and night shifts. The number of staff on duty was not provided in a format that a layperson could understand; it did not indicate the number of individual RN's, LPN's or NA (nursing assistants) working each shift. An individual looking at the posting would not be able to determine how many of each type of staff was on duty without doing a calculation. For example, instead of indicating the number of NA's working the day shift on 12/4, the posting indicated NA hours were 30.25 and 3.78 FTE's. In addition, the census didn't reflect the current or accurate census for multiple days according to comparisons between the postings and a document titled Detailed Census Report. For the month of November 2022, the census on the posting was inaccurate 12 times (11/1, 11/2, 11/3, 11/8, 11/9, 11/10, 11/14, 11/15, 11/16, 11/17, 11/29, 11/30). For the month of December 2022, the census was inaccurate five out of seven days (12/1, 12/2, 12/3, 12/4, 12/5). During an interview on 12/7/22, at 8:31 a.m., staffing coordinator (SC)-E, stated she completed and posted the daily nursing staffing posting using a format she was directed to use. During an interview on 12/7/22, at 9:15 a.m., the administrator and social worker (SW)-A were informed the nursing staffing posting didn't meet the federal requirements, specifically it did not indicate the number of staff working in each category and the census was not accurate on a number of dates. The required elements of the regulation were discussed. Facility policy titled Daily Staffing Report dated 3/2016, indicated the facility posted the following information in a prominent location in a clear and readable format. Facility name, date, census, and total number and actual hours worked by registered nurses, licensed practical nurses, trained medication aides, and certified nursing assistants directly responsible for resident care per shift. The staffing coordinator was responsible for posting the staffing information and making changes in a timely manner.

Based on observation, interview, and document review, the facility failed to assess, evaluate and monitor for the reoccurrences of resident-to-resident abuse for 1 of 2 residents (R1) who had a history of [REDACTED]. The immediate jeopardy began on 9/2/20, when the facility failed to prevent R1's recurrent physical aggression towards other residents. The facility had not implemented an effective system of supervision for R1 to remove the risk of continued aggression toward other residents. The administrator and director of nursing (DON) were notified of the IJ on 9/23/20, at 7:27 p.m. The IJ was removed on 9/24/20 at 5:18 p.m., when it could be verified the facility had developed and implemented interventions to minimize risks of resident-to-resident abuse. However, non-compliance remained at the lower scope and severity of D, isolated, no actual harm, with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's Admission Record face sheet printed 9/23/20, included [DIAGNOSES REDACTED]. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had moderate cognitive impairment, exhibited physical behavior towards others and rejection of care 1-3 days during the assessment period, and utilized a wheelchair (w/c) for mobility. R1's care plan last revised 9/10/20, indicated the resident has had episodes of aggressive behavior and has threatened staff as well as other residents. Resident has made inappropriate sexual comments and needs some guidance to maintain optimal social relationships. Interventions included to remove residents whom may be targeted in times of resident's aggression, and 1:1 (one to one) with validation of feelings when resident is frustrated, agitated. The care plan also indicated the resident has had instances of false accusations of others (someone jumped up and down on him, beat him up, etc.) Family have reported that resident makes false statements about staff persons. Interventions included: If resident making untrue accusation, attempt to identify trigger. Remove trigger if able. Male staff being present have triggered this in the past. Report all accusation to nurse in charge immediately. Increase monitoring and provide support and reassurance as needed if resident exhibiting accusations of others, agitation and seeking out others that he is threatening to harm. Monitor for anxiety, distress and / or fear. Remove others from environment if possible. Redirect and offer calm, quiet environment. Investigate any accusations of abuse or harm from resident. If unable to rule out or explain immediately, follow protocol for filing VA (vulnerable adult) incident report to OHFC (Office of Health Facility Complaints-designated state agency) until full investigation can be completed. R1's Visual/Bedside Kardex Report utilized by the nursing assistants (NAs) included: 1:1 with validation of feelings when resident is frustrated, agitated. If resident is agitated, remove peers from area. Allow resident to wander freely in common areas. Limit number of staff for intervention if possible. Staff to monitor resident while in public areas and if appears to be propelling to room, they will follow and assist with any needs he may have, ensuring when they leave that the call light is within reach and needs met. On 9/22/20, at 12:43 p.m. R1 was observed propelling self out of the dining room and down wing 1 in w/c, holding onto the railing and pulling to assist with movement. No other residents or staff were in the hallway on wing 1 at that time. R1 stopped in front a resident room looking in. There was a female resident in the room lying in bed. R1 remained in the doorway to the room looking in for approximately 2 minutes until a nursing assistant (NA) observed R1 in front of the door and redirected R1 back into the dining room. R1's progress notes dated 9/2/20 included: - 18:32 (6:32 p.m.) Behavior Note Note Text: Resident w/ (with) confrontation seeking, accusing people of stealing money from him. Behaviors began at about 1730 (5:30 p.m.). He was given a PRN (as needed) [MEDICATION NAME] (an antipsychotic medication) at the onset of behavior. Resident was served his evening meal and ate 100% of his meal in the dining room. Behaviors began to escalate after he finished eating. Resident wheeling himself up and down the hallway swinging out and grabbing at anyone who walks by him, staff and residents included. Resident wheeling out to dining room for confrontation. Other residents removed to place of safety and staff to give resident space to de-escalate. Will continue to monitor resident from a distance to ensure safety. - 19:07 (7:07 p.m.) Behavior Note Text: Resident continuing to be confrontation seeking, Kicked another resident (medical record number/R3) who had walked out to dining room. (R3) was in the process of being escorted out of the dining room by NAR (nursing assistant registered). (R3) sustained no injuries and was escorted to safety. Will continue to monitor per nursing measures. R1's physician progress notes [REDACTED]. He unfortunately kicked another resident yesterday. This was a female resident, typically in the past his physical aggression has been directed towards males .Assessment/Plan: Unfortunately had escalation of physical interaction with another resident, kicking them yesterday. Staff note that his behavior seem to be escalating on daily basis and looking at his prn [MEDICATION NAME] use it has been more frequent as the month of August progress and daily here so far in September. Consider dose increase in [MEDICATION NAME] verses addition of another [MEDICAL CONDITION] medications such as [MEDICATION NAME] acid (a mood stabilizer), but I do not think that dose would be appropriate directions to go given his level behaviors at this time. Therefore, decision was made to transition to [MEDICATION NAME] (an antipsychotic medication). [MEDICATION NAME] 5 mg (milligrams) is equivalent to roughly 100 mg of [MEDICATION NAME]. Initial dose will be set plants (sic) pain (sic) 5 mg bid with additional 2.5 mg available daily prn. All this will be less of a total daily equaling dose, hoping the [MEDICATION NAME] will be more effective. May need some further titration. Although the facility contacted the physician to address R1's increase in aggressive behaviors there was no evidence the facility had formally increased supervision of R1 or reported the resident-to-resident altercation between R1 and R3 to the state agency (SA). R1's progress notes dated 9/7/20 - 9/8/20 revealed the following: - 9/7/20 01:32 (1:32 a.m.) Behavior Note Note Text: Resident started grabbing peers walker while it was not in use and attempted to throw it around the dinning (sic) area. Resident is taking dinning (sic) room chairs and attempting to throw them and knock them over. Staff attempted to redirect resident by offering a snack. Resident began to swing at staff, hit staff, and kick staff. Resident had gotten ahold a wooden block from activities and was swinging it at staff. staff (sic) redirected resident to other objects such as socks and removed wooden object from residents reach. Staff attempted to stand back and monitor resident to allow him to calm down. Resident continues to wheel around the dinning (sic) area knocking over chairs and moving tables. Resident entered the nurses station cornering nurse he grabbed the cord for the walkie talkie and yanked it out of nurses ear. he (sic) then grabbed basket of items off of the nurses station counter and then threw it on the floor. Staff continued to attempt to safely redirect resident with conversation about his work before retirement. resident (sic) would respond appropriately and maintain a partial conversation while attempting to hit staff. Staff continues to remain a safe distance from resident to allow him to calm down as well as observe resident so that he does not hurt himself or others. staff (sic) will continue to observe. - 9/7/20 02:14 (2:14 a.m.) Behavior Note Note Text: Resident with [MEDICAL CONDITION]- restlessness and multiple behaviors- was pleasant and talkative with staff at beginning of shift- then one of NAR's called for assistance with him d/t (due to) his behavior- became combative-aggressive towards the NAR and then another NAR that responded to try and assist - when this nurse approached his demeanor was totally different than prior- unsure was (sic) escalated the mood change- the NAR stated she was trying redirect and he became agitated and hasn't stopped being combative and agitated towards all staff - this nurse told all staff to stay down their halls and let him be and I would watch over him- educated that the more people that intervene the worse it becomes- he did take his anger out at all that tried to intervene such as another nurse on in training tried to distract him so this nurse could remove the wooden gadget he took out from the activity shelf and was swinging at everything- she did get hit on hand - he pushed dining room chairs into this nurse shins- swinging out-punching out- running into chair and table- tipping chairs over-banging on chairs- hitting with a rolled up newspaper as in swatting flies -- but hard--- no way to offer the prn [MEDICATION NAME] ([MEDICATION NAME]) to calm him- I tried ice cream- he smashed the container all over the table and and floor -this nurse asked if a new face- younger NAR would try to distract him- at first he was being nice towards the new face then she reported he punched her in the left eye - stated he did it so quick when trying to block his hands-- this nurse will interact 1:1 (one-to-one) the rest of noc shift as to no other staff getting hurt - 2 incident's report filled out so far with his combativeness- has had new med change which is not effective to manage this behaviors this far- --has tried to rip the phone off the wall- throwing and shredding boxes- making threatening comments such as I get ahold of you I will punch your eyes out- call the cops- see where that gets ya--will stay at distance to monitor. - 9/7/20 03:29 (3:29 a.m.) Behavior Note Note Text: Resident started with heavy eyes and wearing himself out from non-stop all noc (night) so far- took majority of the oj (orange juice) in with the prn [MEDICATION NAME]- was cooperative with this nurse and other nurse with transferring him into bed with EZ (mechanical device) stand- allowed incontinent cares and also allowed to face wash face and mattered eyes- 02 (oxygen) supplement on and warm blanket from the warmer for comfort- resident very difficult to manage behaviors once he starts- - 9/7/20 23:55 (11:55 p.m.) Behavior Note Note Text: combative, confrontational, active seeking harm towards staff, disruptive yelling out, unable to redirect r/t (related to) behaviors, confusion. verbal and physical threats w/ agitation. striking out, threats to kill everyone. disruptive to facility staff routine of caring for others as Res (resident) will enter others rooms w/ harmful confrontation seeking. - 9/8/20 00:37 (12:37 a.m.) Behavior Note Note Text: staff heard Res (medical record number (MRN)/R3) yelling out help. Res found physically attacking this Res (MRN/R3) while she was sitting in recliner in MDR (main dining room) watching TV. Res striking her, grabbing on RUE (right upper extremity) twisting it attempting to harm. required staff direct intervention for separation of Res r/t behavior w/ disregard to safety of others, confrontation seeking to injure others. accusative (sic) w/ paranoia of others. Res remains disruptive to facility w/ behaviors, calling out, throwing items around MDR and at staff. unable (sic) to deescalate behaviors r/t seeking harmful confrontational behaviors. kicking at, threatening staff In a facility report to the SA dated 9/8/20, at 8:55 a.m. indicated: (R3) was sitting in dining room watching television. Staff heard her calling out for help. Approached and observed (R1) grabbing her right arm and twisting it with the apparent attempt to injure her. Staff intervened immediately and separated residents. (R3) has no injury following incident. (R1) has not sought out resident further since this incident. In the facility's investigative report submitted to SA dated 9/9/20, at 9:10 a.m. indicated R1's care plan was updated to remove others from area if resident expressing physical, threatening behavior and provide 1:1 or close observation as needed to ensure resident and others' safety. The investigation also addressed R1's medication change from [MEDICATION NAME] to [MEDICATION NAME] on 9/3/20, and the residents increase in physical and threatening behavior after the medication was changed. R1's [MEDICATION NAME] was discontinued and [MEDICATION NAME] was resumed as that was more effective in managing the residents behavior. Staff were educated on removing other residents from area if a resident is a risk to harming others. Although the investigative report indicated staff would provide 1:1 or close observation as needed should R1 express physical, threatening behavior, there were no formal parameters in place on when or how this increase in supervision would occur. R1's progress note dated 9/16/2020, at 21:52 (9:52 p.m.) indicated: Incident Note Note Text: Resident became restless, and aggressive with staff and peers. nurse (sic) found resident in dining room with peer (R2) and was using his shirt to attempt to choke him from behind. staff (sic) intervened and separated residents. scheduled (sic) [MEDICATION NAME] given med was ineffective. PRN [MEDICATION NAME] administered. Resident continues to have aggressive behaviors and wandering the hallways. staff (sic) will continue to observe. An investigative report submitted to the SA on 9/17/20, at 14:06 (2:06 p.m.) included: Staff heard (R2) yelling out in the dining room at approximated 7:17 p.m. and responded immediately. Nurse was the first person to respond and witnessed (R1) in his wheelchair behind (R2) in his wheelchair in the main dining room. (R1) was holding (R2) by the shirt and shaking him yelling at (R2) to shut up. The shirt was tight across (R2's) neck but staff stated (R2) was breathing and yelling out. Nurse and CNA (certified nursing assistant) intervened and (R1) released (R2's) shirt. (R2) was examined no injuries noted. Prior to incident no trigger was able to be identified and resident appeared calm with staff interactions. (R1) [MEDICATION NAME] order resumed to 100 mg TID (three times a day) & (and) 100 mg PRN on 9/8/20. This medication has been successful in reducing his target behaviors of paranoia and aggression. During investigation staff reported having the dose earlier than at HS (hour of sleep/8:00 p.m.) would be more effective in preventing these behaviors. (Physician name) was updated and time for one of the doses was changed from HS to 6:00 pm. IDT (interdisciplinary team) will continue to monitor (R1) for effectiveness of [MEDICATION NAME] and update provider as needed. Though the facility contacted R1's physician for time change of the HS [MEDICATION NAME], no formal plan to increase supervision of R1 to protect other residents was implemented. When interviewed on 9/22/20, at 12:03 p.m. NA-A confirmed R1 could be physically aggressive towards staff and residents. NA-A stated R1 had a med (medication) change not that long ago and it seemed like the aggressive behaviors started to escalate with the med change. NA-A confirmed R1 was now back on his original medication (did not name the med) and he seemed better as had not exhibited any aggressive behavior in the past 4 days that she'd been working. NA-A stated if R1exhibited escalating behaviors or was going after other residents the staff would separate the residents and keep an eye on R1 to assure safety for other residents. NA-A further stated when R1 was in the dining room they usually would remove the other residents if his behavior was escalating as that seemed to work better than trying to remove R1. Staff also had shut the fire doors to the wing entrances until R1 calmed down to prevent him from trying to enter other resident rooms. NA-A confirmed staff try to keep eyes on R1, especially if he started to exhibit aggressive behavior, though confirmed no formal plan for supervision was in place. When interviewed on 9/22/20, at 4:40 p.m. NA-B confirmed having worked the evening of 9/16/20, though did not witness the altercation between R1 and R2. NA-B stated R1 was kind of iffy that night as to whether he needed a PRN [MEDICATION NAME] or not with the behaviors he was exhibiting. NA-B stated R2 and R3 were in the dining room with R1 just prior to the incident. NA-B had left the dining room area and the altercation happened shortly after that. NA-B confirmed licensed practical nurse (LPN)-A was also working that evening and thought she was the one that came upon the incident first between R1 and R2. NA-B stated staff try to keep visual on R1 and if they don't see him around will walkie each other to see who has eyes on him. NA-B confirmed there were no staff present in the dining room when the incident occurred between R1 and R2. When asked if R1 ever targeted any other residents she confirmed R1 had kicked R3 and also goes after R7 at times or depending upon his mood ,could turn on anyone. NA-B confirmed R1's physical behaviors included hitting, kicking, ramming chair into people or throwing things when agitated. NA-B denied any formal documented increased supervision for R1. When interviewed on 9/22/20, at 4:50 p.m. licensed practical nurse (LPN)-A confirmed having worked the evening shift on 9/16/20, and coming upon the altercation between R1 and R2. LPN-A stated not being sure what triggered the event; she was down wing 3 and heard R2 yelling. I turned and I looked and could see that (R1) had ahold of (R2's) shirt from behind and was trying to choke him with it. LPN-A stated she and NA-A separated R1 and R2 then brought R2 back to his room. LPN-A confirmed R1 remained in the dining room as there was no getting him back to his room. LPN-A further confirmed there were no staff or other residents in the dining room at the time of the altercation. LPN-A stated the staff all kind of took turns monitoring R1 after the incident with the walkie talkies and kept an eye on him at all times. LPN-A stated she had never seen R1 become physically aggressive with another resident though had with staff. LPN-A confirmed prior to the incident on 9/16/20 there was not extra supervision for R1. LPN-A stated at this time if staff start to see R1 get agitated they keep a closer eye on him, and further stated the night of 9/16/20, there wasn't the signs like he wanted to leave or stating someone was after him- that night there wasn't any trigger to make them think he needed increased supervision. LPN-A confirmed there was no formal documented increased supervision in place for R1. During an interview on 9/23/20, at 11:03 a.m. with LPN-B and registered nurse (RN) -A, LPN-B confirmed having worked the evening of 9/2/20 when R1 kicked R3. LPN-B confirmed R1 was agitated that day and the staff had moved all the residents out of the dining room. R3 had walked into the dining room independently so one of the NA's went into the dining room to redirect R3 back to her room. LPN-B stated when the NA started walking with R3 back to her room R1 went after R3 and kicked her. LPN-B confirmed she had not witnessed the altercation but was told this by the NA who did. LPN-B stated she would check in with other staff to see how R 1 was doing and what his mood was throughout the shift. If R1 was wandering up and down the halls they try to keep eyes on him and communicate his whereabouts. RN-A stated if it's a busy time such as at mealtime when the NA's are assisting residents with eating, they involve activity staff with keeping an eye on R1 so he wouldn't go into another resident's room. RN-A further stated R1 had never done that but they want to make sure it wouldn't happen. LPN-B stated if R1 was agitated at times they would shut the fire doors from the dining room into the wings to protect the other residents; if R1 was already in a hallway they would keep eyes on him. LPN-B stated sometimes R1's mood could change very quickly-could be smiling and happy one minute and then can get angry the next. When the resident was agitated is best to watch him from a distance as he doesn't want staff's one to one attention and also would strike out at staff when agitated. RN-A and LPN-B confirmed since R1's antipsychotic medication was changed back to [MEDICATION NAME] and with the dosing time changes his mood had been better though was still doing a lot of wandering but not as aggressive. When interviewed on 9/23/20, at 12:44 p.m. case manager registered nurse (RN)-B stated R1 typically targeted aggression towards certain residents, and staff could usually tell when R1 was ramping up. Staff would then get the other residents out of R1's area which was usually the dining room. RN-B confirmed R1 would target R3 and R7, though R1 had never been physically abusive with R7, more verbal. RN-B confirmed R1 kicked R3 one weekend, a couple times, mostly he thinks R3 is his wife. Related to the altercation between R1 and R2 on 9/16/20, RN-B stated, That was an unusual situation, he usually doesn't go after (R2). RN-B confirmed both altercations occurred in the evening and staff were monitoring R1 every 30 minutes to one hour and that should be documented. RN-B further confirmed the increased monitoring was implemented after the first time R1 kicked R3 on 9/2/20. After the incident between R1 and R2, RN-B stated to her knowledge R1's supervision continued at 30 minutes to an hour checks. RN-B and RN-A checked the electronic medical record (EMR) to verify documentation of increased supervision of R1 following the incidents with R3 and R2. RN's were unable to locate evidence of increased monitoring in the EMR. RN-A stated she would also check her office as staff may have been documenting the increase in supervision on paper. RN-A further stated on the evening of 9/16/20, following R1's altercation with R2, the director of nursing (DON) had come into the facility and provided 1:1 supervision of R1 for a period of time. When asked what staff would do to keep residents safe after a physical altercation, RN-B confirmed supervision would be increased. RN-B stated R1's aggressive behaviors typically happened on the evening shift. The evening shift knew if R1's behaviors started to increase to utilize the prn [MEDICATION NAME] and they were good about doing that. RN-A and RN-B were unable to find any evidence of increased monitoring of R1 by staff either on paper or in the EMR. When interviewed on 9/23/20, at 1:39 p.m. the director of nursing (DON) stated at the time of the incident on 9/2/20 when R1 kicked R3, staff were trying to keep R3 safe by getting the resident out of the dining room where R1 was located. DON confirmed the altercation was not reported as a VA as R3 had no injury, though in hindsight should have reported it. DON stated that when R1 is ramping up staff try to get everyone out of the dining room. R3 is strong willed and sometimes doesn't want to leave. If we can see that R1's behavior is escalating sometimes would have a staff member stay in the dining room with him - sometimes it's hard to know when it's coming. DON stated at times the nurse of trained medication aide (TMA) will station the med cart in the dining room to stay in visual sight of R1 while passing medications to keep an eye on him. DON confirmed the resident would not be 1:1'd at that time but would be less then 30 minutes between visual checks. After the incident during the early morning of 9/9/20 between R1 and R3, night staff were re-educated that R3 was not to be going out to the dining room when R1 was up and out there. DON confirmed R3 was in the recliner resting when R1 came upon her. DON further confirmed R1 was exhibiting behaviors that evening and would have expected staff to remove R3 out of the dining room and did retrain them about that as well. When interviewed on 9/23/20, at 3:20 p.m. NA-D confirmed having worked the night shift on 9/7/20 into the morning of 9/8/20. NA-D confirmed R1 had been combative that night and had punched one of the NA's in the eye. NA-D stated R3 was sleeping in the recliner in the dining room. NA-D was doing her rounds and could hear R3 screaming; by the time NA-D got to the dining room the nurse had got in between R1 and R3. NA-D thought R3 was just scared because R1 had grabbed a hold of her and wouldn't let go until the nurse snatched him away. NA-D confirmed knowledge of R3's presence in the dining room and stated, Everyone knew she was out there because she's always there at night. NA-D stated R3 sleeps wherever she wants and lots of times will sleep in the chair by the nurses station, she never stays in her room. NA-D was not sure if the facility was doing any increased monitoring/supervision of R1 as she no longer worked at the facility. When interviewed on 9/23/20, at 3:34 p.m. LPN-C confirmed having worked the night shift on 9/7/20 into the morning of 9/8/20. LPN-C stated R1 was very agitated all day from what he understood; this was pre-[MEDICATION NAME] because they had put him on [MEDICATION NAME]. R1 was attacking the staff which was normal when he got like that. R1 was the only one up at the time; R3 had been up and about and then went back to her room. Then I heard R3 hollering, Help, help, help!. Screaming it rather than just saying it like she usually does. R1 was grabbing on R2's right arm, hunched over in his w/c. I don't' know if he hit her but he was grabbing on her arm threatening her. LPN-C confirmed separating R1 and R3 then another staff went with R3 to her room. At one point R1 went down to R3's room and staff redirected him. R1 laid down about 5:00 a.m. but was back up around 6:00 a.m. when I left for the day. LPN-C stated he had no knowledge that R3 had come back out to the dining room. I didn't even hear her until she started screaming help. I didn't know she was out in the dining room, had I known I would have redirected her back to her room. When R1 is in one of those moods he's attacking everyone so we make sure the other residents are away from him cuz there's no way you're gonna keep him isolated. The night crew all know that if R1 is in this type of agitated mood that the other residents need to be separated from him. LPN-C confirmed R1 had gone after other residents in the past but it had been awhile and that's before he was on any [MEDICAL CONDITION] medications. LPN-C further confirmed R1 and R7 had gotten into it before. LPN-C wasn't sure if R1 was on any increased monitoring/supervision as had been on vacation for the past 2 weeks. When interviewed on 9/23/20, at 5:53 p.m. the DON confirmed the facility had not implemented formal documented monitoring/supervision for R1 related to the incidents of resident-to resident abuse. The facility policy titled, Resident Protection Plan revised October 2019, included: Physical abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. The immediate jeopardy that began on 9/8/20, was removed on 9/24/20 at 5:18 p.m., when the facility developed and implemented interventions to ensure residents at risk for resident-to resident abuse were safe by: Implementing 30 minute checks for R1 with documentation of any behaviors displayed. Assigning one staff each shift to be responsible for R1's 30 minute checks, 1:1 the resident should he display any symptoms that may indicate he could harm himself or other residents, and to remove all residents who may be in danger. Finally, the facility comprehensively assessed R1's cognitive status and risk factors noting symptoms associated with past aggression to include: paranoia; accusatory statements toward staff or other residents; verbal aggression; resistance with cares; moving quickly in the halls or dining room; moving furniture; talking about going home.

Based on interview and document review, the facility failed to ensure resident-to-resident abuse was reported to the State Agency (SA) in a timely manner in accordance with established policies and procedures, for 1 of 3 residents (R3) who were reviewed for abuse. Findings include: R3's Admission Record printed 9/23/20, included [DIAGNOSES REDACTED]. R3's annual Minimum Data Set (MDS) assessment dated [DATE], indicated R3 had moderate cognitive impairment and exhibited wandering behavior 4-6 days but less than daily during the assessment period. The MDS further indicated R3 was independent with locomotion on the unit. Review of the care plan last revised 9/15/20, indicated R3 was a vulnerable adult (VA) due to physical and cognitive impairments. Interventions included to report all allegations of abuse/maltreatment toward resident immediately to the state agency (SA). Complete investigation and put interventions in place to protect residents from future instances. Review of R3's Field Crest Care Center Resident Incident Report dated 9/2/20, at 8:00 p.m. indicated the following: This resident was kicked by another resident (medical record number/R1) in the right lower leg. This resident sustained [REDACTED]. Denies pain r/t (related to) incident, stating that it wasn't hard and didn't hurt. Altercation was witnessed by NAR (nursing assistant registered). Will continue to monitor per nursing measures. There was no evidence to indicate the altercation had been reported to the SA. Review of a facility provided allegation report submitted to the SA on 9/8/20 at 8:55 a.m., indicated a resident to resident altercation had occurred. R3 was in the dining room watching television when staff heard the resident calling out for help. When staff went into the dining room they observed R1 grabbing R3's right arm and twisting it with the apparent attempt to injure her. Staff intervened immediately and separated the residents; R3 was not injured. The report further indicated the altercation occurred on 9/8/20 at 00:30 (12:30 a.m.), 8 hours and 25 minutes earlier. The facility failed to report the allegation to the SA immediately. When interviewed on 9/23/20, at 1:23 p.m. the social services director (SSD) confirmed the altercation between R1 and R3 on 9/2/20, had not been reported to the SA. SSD was unsure why the director of nursing (DON) chose not to report the incident to the SA. SSD further confirmed the altercation between R1 and R3 on 9/8/20, was reported late to the SA. SSD stated the morning of 9/8/20, having read the progress notes and knew immediately that the incident should have been reported within 2 hours. SSD further stated having talked with the nurse on duty present during the incident (licensed practical nurse (LPN)-C) who indicated had tried to report the incident to the SA after it occurred but had difficulty getting through. SSD confirmed LPN-C had not notified other staff the incident still needed to be reported. SSD stated having educated LPN-C to call SSD if having problems with filing VA reports timely. When interviewed on 9/23/20, at 1:39 p.m. the director of nursing (DON) confirmed the altercation between R1 and R3 on 9/2/20, had not been reported to the SA. DON stated they weren't sure how much contact there was with R1 kicking R3 as there was no injury or redness on R3's right lower leg, though in hindsite the incident should have been reported. The facility policy titled, Resident Protection Program-Investigation, last revised October 2019, included: 1. An incident or suspected incident of mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of property must be immediately reported to the administrator. The administrator will be notified in person or by phone. 2. An initial report will be completed and submitted to the state agency via Office of Health and Facility Complaints. (Refer to the Reporting a Vulnerable Adult Incident). a. If the allegation involve abuse or result in serious bodily injury the report must be made no later than 2 hours after the allegation is made.

Based on interview and document review, the facility failed to ensure oxygen was supplied as prescribed by the physician for 1 of 1 resident (R240) reviewed for oxygen usage. This resulted in an immediate jeopardy (IJ) finding when R240's oxygen saturations (O2 SAT's) level dropped causing R240 to experience difficulty in breathing. The facility had developed and implemented interventions prior to survey so the finding is being cited at past non-compliance. The past non-compliance IJ began on 10/23/19. The IJ was removed and the deficient practice was corrected by 10/24/19, when the facility had developed and implemented a plan to prevent recurrence including a system to check for equipment and supplies needed before residents leave the facility. The administrator and director of nursing were notified of the past non-compliance IJ at 3:20 p.m. on 12/11/19. Findings include: R240's Admission Record dated 12/12/19, included [DIAGNOSES REDACTED]. In a report to the State Agency 10/23/19, it was identified R240 had arrived at (name of hospital) [MEDICATION NAME] radiology department via private transport company for a planned procedure from the nursing home. The report indicated family member (FM)-E arrived separately and met the resident in the waiting room. R240 and FM-E were brought into the radiology pre-procedure area for evaluation where staff immediately assisted R240 to transfer from the cart to the bed. The report indicated following transfer to the bed, FM-E had alerted staff that in the waiting room R240 was complaining of breathing difficulty. At that time, FM-E reported to the hospital staff that R240 was oxygen dependent at the nursing facility requiring oxygen via NC (nasal cannula) at all times. The report further indicated hospital staff immediately obtained a pulse oximetry level for R240 and his oxygen level was 70% on room air. The report described R240 as hypoxic, ashen and not responding to verbal or physical stimuli. At that point, hospital staff placed R240 on a simple mask at eight liters for a slow increase in his oxygen levels to 94%. Hospital staff then contacted the skilled nursing facility to report the patient had been transferred to the hospital in Rochester from Hayfield, Minnesota, a 45 minute drive, without his prescribed oxygen. R240's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R240 was cognitively intact and required the use of oxygen for respiratory treatment. R240's physicians orders dated 9/23/19, included orders for oxygen (O2) via NC at 2 liters per minute every shift related to hypoxemia and chronic heart failure. R240's care plan initiated 10/10/19, indicated the resident required oxygen therapy for hypoxemia, secondary to chronic [MEDICAL CONDITION], cough and deep breath while awake. The care plan also included, (MONTH) use Oldness incentive spirometer (a device that measures how deeply a person can inhale) to assist with deep breathing; Give medications as ordered by physician; Observe and document side effects and effectiveness; O2 via nasal cannula; Position resident to facilitate ventilation/perfusion; and to use upright, high Fowlers position (a semi-sitting position 45-60 degrees) whenever possible to allow for optimal diaphragm. R240's Progress Notes, included the following: 10/22/19, spoke with (FM-G) about chest x-ray results from today. Large left pleural effusion (is the build-up of excess fluid between the layers of the pleura outside the lungs) with associated compressive atelectasis (the reduction in lung volume is greater than its normal relaxed state)/consolidation. Trace right pleural effusion. Physician assistant consulted with medical doctor and agree to move forward with [MEDICATION NAME] (a drainage catheter and drainage bottles that collect fluid) as ordered tomorrow (10/23/19). 10/23/19, resident left to doctor appointment via stretcher at 8:45 a.m. Family to meet at appointment. Review of a Registration and Disposition of Complaints form dated 10/23/19, indicated on 10/23/19 the resident had been sent to Rochester for appointment via quality stretcher without ordered oxygen and in [MEDICAL CONDITION] (stating at 64%). During an interview on 12/11/19, at 12:11 p.m. FM-E confirmed R240 had been brought by stretcher in a transportation van for a procedure at the Rochester hospital. FM-E stated he had met R240 at the hospital and did not notice right away that R240 had no oxygen on. FM-E stated, He was always on oxygen. FM-E stated when moving R240 from the stretcher to the bed, R240 sat up on the bed and stated, I can't breathe. FM-E stated R240 had asked the van driver where the oxygen was and the van driver had said he didn't know. FM-E said it had been determined R240 hadn't been sent with his oxygen. FM-E the stated he'd told the hospital nurse R240 required on two liters of oxygen, and when the nurse checked R240's levels and he was at 63% and was hypoxic. FM-E stated the nurse immediately put a face mask on R240 and turned up the oxygen to eight liters. FM-E stated he could see R240 was struggling to get air but stated after the O2 was applied, R240 settled down after taking a couple of deep breaths. During interview on 12/11/19, at 12:41 p.m. trained medication aide (TMA)-B stated she was working the day R240 was sent to his appointment. TMA-B stated nursing assistant (NA)-A and licensed practical nurse (LPN)-A had prepared R240 for his appointment. R240 had to be transferred onto a stretcher with a lift. TMA-B stated there was a call later from the hospital informing the staff R240 had not had oxygen sent with him to his appointment and had become hypoxic. TMA-B stated R240 was suppose to have oxygen continuously. During interview on 12/11/19, at 12:51 p.m., NA-A verified she had helped to transfer R240 from the wheelchair to the stretcher. NA-A stated she was not sure whether R240 needed oxygen or not, and stated LPN-A had come in. NA-A said she'd asked LPN-A whether R240 needed oxygen or not, and her (LPN-A) response was she was going to finish up doing the paper work and would take care of the rest of it. NA-A said she'd left R240's room and had assumed LPN-A was going to take care of the oxygen when she finished up with the transportation service. NA-A said she should have gone back to check with LPN-A to ensure oxygen was going with R240 but hadn't. She stated later that day, one of the charge nurses had asked her if she'd sent oxygen with R240, and she'd said, No. NA-A stated she'd heard R240 went all the way into his appointment without any oxygen. During interview on 12/11/19, at 12:59 p.m. LPN-A stated, It was hectic that day (date of appointment, 10/23/19). LPN-A stated she'd helped transfer R240 onto the stretcher using a Hoyer (full body mechanical lift). She stated, The stretcher would not go down after (R240) was placed on it and I was worried (R240) was going to fall. LPN-A said the staff placed the stretcher straps on R240, and had applied a blanket because R240 had said he was cold, then they sent him (R240) on his way. LPN-A stated she had later been updated R240 was sent without oxygen to his appointment. LPN-A stated the director of nursing (DON) had informed her R240 had gone into respiratory distress due to not having oxygen sent with him for his appointment. LPN-A verified R240 required oxygen continuously and confirmed she had not sent oxygen with R240 to his appointment. During interview on 12/11/19, at 1:06 p.m., the DON stated before R240 left the facility for his appointment, the staff had removed his (R240's) oxygen in order to transfer him onto the gurney. The DON stated, Just when the nurse thought about putting (R240's) oxygen back on him he had asked for a blanket, (LPN-A) went to get the blanket and (R240) was on his way out the door. She (LPN-A) forgot to send his oxygen with him. The DON stated she understood R240's medical condition and verified R240 had experienced respiratory distress when he'd arrived at the hospital for his appointment. The DON also verified R240 was to have continuous oxygen in place. During interview on 12/11/19, at 1:23 p.m. the facility's social worker (SW)-A, stated she'd first become aware of R240 not having oxygen available when he'd gone to his appointment when she received a phone call from FM-[NAME] SW-A stated she'd documented the concern on a facility complaint form. Further, SW-A stated FM-G had informed her R240's oxygen saturation level had dropped very low, and FM-G was understandably upset. During interview on 12/11/19, at 1:30 p.m. registered nurse (RN)-C stated the hospital had called and informed them R240 had been transferred to his appointment without his oxygen. RN-C stated she'd talked with the hospital nurse and had coordinated to ensure R240 would have oxygen for his transport back to the facility. During interview on 12/11/19, at 1:39 p.m. RN-D stated someone from the hospital had called to inform them R240 had arrived at his appointment without oxygen and was in acute distress. RN-D stated, If I remember right his oxygen saturation was only at 60 to 70 percent. During interview on 12/12/19, at 9:11 a.m. the hospital's RN-F stated, (R240) was scheduled to have a procedure as an outpatient and had been transferred here from the facility via a transport service. His family met (R240) in the lobby and relayed (R240) was short of breath. We immediately came out to get the patient. He was very somnolent (sleepy/drowsy). RN-F stated she'd asked the family whether R240 required oxygen at the facility and FM-E had responded, Yes, he is on 2-3 liters all the time. RN-F stated she'd asked if FM-E whether any oxygen had been sent with R240 to the appointment. RN-F stated, The transportation company had stated they had not been told (R240) needed to be transported with oxygen. RN-F said she'd immediately hooked R240 to a pulse oximeter and applied oxygen. RN-F confirmed R240's oxygen saturation was in the 70's, but slowly returned to the low 90's with the oxygen on. RN-F said R240's color was gray and FM-E was visibly concerned and had reported, They never even take his oxygen off when he is transferred from the bed to chair, he has oxygen on all the time. RN-F stated she'd then called the facility and asked how this could happen, and they'd said they didn't know how it could happen, but would look into it. RN-F stated, (R240) had a lack of oxygen for at least the 45 minute drive from the facility to the hospital. The facility's 9/17/13 revised policy Storage, Maintenance, Handling and Use of Oxygen included: To ensure oxygen and oxygen equipment are safely stored, readily available, and appropriately administered to residents with respiratory difficulties. Procedure for use of oxygen: Administer according to physician's orders [REDACTED]. The past noncompliance IJ began on 10/23/19. The IJ was removed and the deficient practice corrected by 10/24/19 when the facility implemented a corrective action. Verification of the corrective action implementation was confirmed by observation, interview and document review. The facility initiated placement of a resident sign out book in the medication room which included a check list of items, including oxygen, that may need to be sent with residents before leaving the facility. In addition, a sign was observed to have been placed on the front door of the facility to Check with a nurse before leaving the building, to ensure families and transportation providers would check to make sure they had all required equipment before leaving the building. During interview with licensed and unlicensed nursing staff, it was determined they understood the importance of using the check list, and had received education on the protocol. In addition, licensed staff were aware of the facility's portable oxygen available for use.

Based on interview and document review, the facility failed to establish an on-going infection prevention program including comprehensive analysis and interpretation of data to identify and respond to possible patterns of infection. This had the potential to effect all 37 residents in the facility. Findings include: On 12/11/2019, at 9:15 a.m. the director of nursing (DON) was interviewed on the facility infection control program. The DON shared the facility infection preventionist was currently on maternity leave. The DON stated for QAPI the facility presented on infection control and documented the analysis of infections. Copies of the data analysis was requested and surveyor was provided with the data analysis completed for the (MONTH) 11, 2019 QAPI meeting. The DON stated that was the only documentation of the data analysis for antibiotic use and infections in the last year. The DON stated she was aware the data analysis was not being done for infections and antibiotic usage as she attended the QAPI meetings. The Infection Prevention and Control Surveillance Policy dated 7-31-19 included, Data Analysis: The Infection Preventionist with the assistance from the IDT will utilize the information collected from the surveillance in order to identify opportunities for improved care and process and identify an action plan for follow up and corrective action reporting. Plan: Based on the analysis of data, develop and implement an action plan that includes corrective actions and staff education.

Based on observation and interview the facility failed to ensure a response when temperatures for refrigerated medications fell below safe storage ranges, and facility failed to remove a bottle of expired [MEDICATION NAME] (TB testing solution) from the medication storage refrigerator. The expired [MEDICATION NAME] had the potential to affect any new admits or new staff after the date of [DATE] and the stored immunizations had the potential to impact any resident whom might have received a dose after the temperature dropped below safe storage levels. During an observation of the facility medication storage area on [DATE], 2:10 p.m. a document titled Daily Refrigerator/Freezer temperature year: 2019 was posted on the facility refrigerator for storing medication. The document covered the months of October, (MONTH) and (MONTH) up unto the date observed, [DATE]. A trained medication aide (TMA)-A stated the night nurses were responsible to record the temperatures each night shift. The temperature log was reviewed and found that the recorded refrigerator temperatures fell below a posted 35 degrees F for safe storage of medications as follows: December: [DATE]- 32 degrees [DATE]- 30 degrees [DATE]- 30 degrees [DATE]- 32 degrees [DATE]- 32 degrees [DATE]- 30 degrees [DATE]- 32 degrees [DATE]- 32 degrees. November: [DATE]- 30 degrees [DATE]- 34 degrees [DATE]- 30 degrees [DATE]- 30 degrees [DATE]-30 degrees [DATE]- 32 degrees [DATE]- 34 degrees [DATE]- 30 degrees [DATE]- 32 degrees [DATE]- 32 degrees [DATE]- 30 degrees October: [DATE]- 32 degrees [DATE]- 32 degrees [DATE]- 34 degrees [DATE]- 34 degrees [DATE]- 32 degrees [DATE]- 32 degrees [DATE]- 34 degrees [DATE]- 32 degrees [DATE]- 34 degrees [DATE]- 32 degrees [DATE]- 34 degrees [DATE]- 32 degrees [DATE]- 32 degrees At the time of the observation a registered nurse (RN)-A confirmed the temperatures were out of range for safe storage of medications and stated a response to the temperature would depend how long the refrigerator had remained at the posted temperature. The refrigerator was observed to have a thermometer that was sitting near the back of the refrigerator at that time which read approximately 43 degrees and RN-A confirmed the temperature at that time fell into the green range marked on the thermometer as appropriate for storage. RN-A stated it was unknown how long the refrigerator had remained below the safe storage temperature on the posted document and said they would need to contact the pharmacy to see what should be done with the stored medications. The medications observed to be in the refrigerator at that time were: Five unopened insulin pens containing [MEDICATION NAME] delivered that afternoon, [DATE] belonging to resident (R16). Four unopened vials of stock [MEDICATION NAME] B ([MEDICAL CONDITION] immunization solution) not opened, delivery date unknown. Three boxes with 22 doses remaining of [MEDICATION NAME] (influenza immunization) with eight doses missing. The box indicated the solution should have been stored at a temperature of no less than ,[DATE] degrees. It could not be determined who would have received the 8 missing doses or when they were administered. One box of nine Flucelvax doses with one missing. The box indicated the vaccine was to be stored between the temperatures of 36 and 46 degrees and do not freeze. It could not be determined who would have received the missing dose. According to an interview on [DATE], at 2:12 p.m. the director of nursing (DON) confirmed the refrigerator temperatures often fell below the safe storage temperature. DON was unable to confirm the medications were still safe to use. At that time, a container of [MEDICATION NAME] serum (to test for [MEDICAL CONDITION]) was found in the refrigerator, opened but marked as do not use after [DATE]. DON confirmed that the solution would be considered expired, but she was unable to confirm if the solution was used after [DATE]. Unknown if anyone received a test dose with possible frozen serum. DON stated she was going to call the pharmacy about what should be done. On [DATE], at 3:52 p.m. DON reported the pharmacy told her to destroy all of the medications except the insulin as they were no longer any good. At 3:57 p.m. DON reported the consulting pharmacist referred her to the Medical Director but did not feel there should be any ill effects from the medications if they had been given after having been frozen. At 4:11 p.m. the DON reported the Medical Director told her there should not be any problems and recommended against re-vaccinating any residents in the facility. A policy related to safe storage of medications was requested. A document titled Medication Storage dated [DATE] was provided and addressed medication storage. The policy indicated medication with storage requirements for temperature, light or humidity controls must be stored to meet specifications for the medication and medications will be monitored by the Nursing Staff to assure that they are not expired, contaminated, or unusable. Policy failed to indicate actions to take if a problem with medication storage should occur, such as low temperature readings for refrigerated medications. According to the Centers for Disease Control (CDC) influenza vaccines are cold sensitive and damaged rapidly by freezing temperatures. Additionally, the CDC indicated, The desired average refrigerator vaccine storage temperature is 40°F (5°C). Exposure to temperatures outside these ranges may result in reduced vaccine potency and increased risk of vaccine-preventable diseases.

Based on interview, observations and record review, the facility failed to reassess nutritional needs for 1 of 1 resident's (R185) who was reviewed for unplanned weight loss. Findings include: R185's admission Sheet and [DIAGNOSES REDACTED]. R185's care plan dated, 8/19/19 and revised 11/01/19 indicated, The resident has nutritional problem or potential nutritional problem r/t (related to) weaning from tube feedings & altered diet: general, mechanical soft textures. Thin liquids, house supplement 4 oz. TID (three times daily), 1.5 liter fluid restriction. The listed interventions included: Monitor/document/report PRN (as needed) any s/sx (signs or symptoms) of dysphagia . refusing to eat, provide and serve supplements as ordered: House Supplement, 8 oz. TID, Provide, serve diet as ordered: general, mechanical soft textures, thin liquids, 2500 fluid restriction, 1500 minimum . R185's list of weights: 8/15/19 was 192.4 pounds (lbs) 9/10/19 was 206.4 lbs 9/19/19 was 199.1 lbs 10/11/19 was 189.7 lbs 10/19/19 was 188.7 lbs 11/6/19 was 182.7 lbs 11/20/19 was 180.8 lbs 12/11/19 was 177.5 lbs R185's Nutrition assessment dated [DATE] read no weight loss and did not indicate the 12.8 lbs loss since admission. During an observation on 12/10/19 at 11:42 a.m. R185 was brought to the dining area for the noon meal. His meal was delivered eight minutes later; however, R185 was observed to have only eaten a few bites and after ten minutes later suddenly stood up and left the room. He was observed shortly afterwards shouting in a charting room that he was able to care for himself and he did not understand why he was in the facility. During an observation on 12/11/19 at 8:18 a.m. R185 was in the dining room and received his meal. Staff were not observed to interact with him. R185 remained in the dining area for approximately 15 minutes and left the table after drinking a small glass of juice and taking a few bites of fruit sauce. His cereal and coffee cake were both untouched. R185's dietary intake for the last 2 weeks was reviewed, indicated R185's had 42 meals offered and R185 ate less than 50% at 19 of those meals, ate 25% or less at 19 of those meals and refused to eat anything at four meals. R185's quarterly Minimum Data Set (MDS) assessment dated , 11/21/19 indicated R185 has impaired cognition, highly impaired vision and requires supervision with eating with one person assistance. During an interview on 12/11/19 at 10:05 a.m. registered nurse (RN)-A stated R185 was cognitively aware and knew how to eat and did not require assistance during meals. During an interview on 12/11/19, at 8:54 a.m. certified dietary manager (CDM) said the facility works as a team when a resident has weight loss. CDM stated she generally would check documented resident weights on a daily basis and looked for those that the system would flag as having weight loss. She stated the interdisciplinary team (IDT) would discuss reasons for weight loss so they could choose appropriate interventions. CDM indicated she was aware of R185's nutritional issues and stated he had had a feeding tube, but this had recently been removed. CDM stated he was to be seen by the dietician monthly due to weight loss and his feeding tube. CDM confirmed she had done his most recent nutritional assessment which resulted in a score indicating he was of low nutritional risk. CDM stated she did not give such a score and the score was simply generated by the system. CDM confirmed that R185 continued to lose weight since admission and said the dietician should have written notes documenting her assessment and plan for him. CDM was unable to locate any dietician notes in R185's record. CDM stated the dietician had last seen R185 on 10/24/19 without any recommendations, but CDM did not have a record of him being seen in November. CDM stated that if weight loss had not stabilized within about a week of occurrence further efforts to address the problem should be initiated. Other than an increase in the amount of dietary supplement on 10/31/19, CDM was unable to confirm other interventions taken to reduce R185's nutritional risks and his weight loss. She stated they did provide snacks, but confirmed he did not appear to care for them and she did not know if he ate them. A request was made for the dietician's progress notes. Facility provided documents titled Dietary Consult Report with handwritten notes for various residents. The notes related to R185 were as follows: 8/28/19, enteral fdg (tube feedings)-comfort cares 9/19/19, nothing written for R185 10/24/19- 2Lfl rest (two liter fluid restriction)-hold feeding if diet intake greater or equal to 50%. Weights look stable- admit 192.4, 9/6=205, 10/24 188.9 down 7.9% no doc of [MEDICAL CONDITION]. Wt (weight) on lift- (blank), wt on w/c (blank) wt on stand (blank) 11/26/19- nothing written for R185 According to an interview on 12/12/19, at 9:11 a.m. nurse practitioner (NP) and R185's physician (MD) stated they were both aware of R185's weight loss. NP stated the CDM kept her updated on his condition and his weight loss was of concern to them. She had not heard from the dietician. MD stated an expectation for the dietician to be following R185's case as he had been on a tube feeding, had weight loss and they were reluctant to try pharmaceuticals to stimulate his appetite as it would increase his fall risk. According to an interview on 12/12/19, at 9:22 a.m. director of nursing (DON) stated that R185 was offered snacks between meals, but she was aware he was not a snack eater. DON stated an expectation for staff to encourage R185 at meals and to offer alternative foods if not eating. DON stated they had discussed concerns about R185's weight loss at IDT meetings and confirmed his weight loss was significant. DON did not know if his situation indicated a need to be seen by a dietician. DON was unable to state any other interventions the facility had taken to encourage R185's intake or reduce his nutritional risks and weight loss. A call was placed to the facility consulting registered dietician 12/11/19, 9:46 a.m. with a message left to return a call; however, dietician did not return the call. A policy related to significant weight loss and/or dietician visits was requested. A policy titled Immediate Temporary Interventions for Unintended Significant Weight loss with a copyright date of (YEAR) was provided. The policy indicated the registered dietician (RDN) or designee will review all significant/severe weight losses monthly or more often as needed and assess nutritional status . the RDN or designee will determine a monitoring system to evaluate the success of the interventions initiated. The facility provided a policy titled Transitioning from Enteral Feedings to Oral feedings with a copyright date of (YEAR). The policy indicated the RDN would work closely with the speech language pathologist (SPL), the nursing supervisor and physician to accomplish the transition. The policy further indicated the facility staff will intervene as appropriate for poor food/fluid intake, weight loss, or other negative reactions to the discontinuation of the enteral feeding, and refer to the RND, SLP and physician as needed .the nursing staff and physician will work closely with the RDN and the SLP to assure the best quality of care for the individual involved.

Based on observation and interview the facility failed to ensure that staff followed professional standards of practice of medication administration for 2 of 10 residents (R1 and R25) observed during a noon medication pass. Findings include: R1's Admission Sheet indicated R1was admitted to the facility with a principle [DIAGNOSES REDACTED]. R25's Admission Sheet indicated R25 was admitted to the facility with a principle [DIAGNOSES REDACTED]., and had a recent [DIAGNOSES REDACTED]. On 12/10/19 11:30 a.m. a trained medication aide (TMA-A) was observed to inform R25 that he was due for his nebulizer treatment and would give it to him as soon as he finished his meal. TMA-A then went to the medication cart and opened the medication drawers. A computer was available on top of the medication cart to refer to resident Medication Administration Records (MAR) during medication set up; however, the screen for the MAR was observed to be in locked mode so the MAR was not open for viewing or documentation. TMA-A placed several paper medication cups on top of the cart and removed several cards from the drawer. TMA-A looked at the cards and punched several small yellow pills into one of the yellow cups; took another medication card and punched out a small white pill into the paper medication cup. TMA-A then placed one paper cup on top of the medications that had been removed from the cards and placed the cups, with medications, in her right pocket. The cups were not observed to have been marked in any way to identify the contents or the name of the resident to receive them. TMA-A then removed a package of what appeared to be a solution for nebulized medication and placed it in her right pocket. Shortly after, R25 finished his meal and TMA-A assisted him to his room. She removed the cup of medications from her pocket and set them on the over bed table in R25's room and then removed the package of solution from her pocket. The label of the package indicated the contents to be Ipratrobium-[MEDICATION NAME] Solution 0.5-2.5 MG/3Ml. TMA-A placed the nebulizer machine on R25's bed and filled the medication cup, attached this to a face mask and applied this to R25's face. TMA-A started the machine and said she would be back in about ten minutes. TMA-A picked up the paper cup of pills, left R25's room, and went to R1's room. She poured the pills onto the bedside table, two and a half small yellow pills and a small white pill and told R1 she had his [MEDICATION NAME] pills for [MEDICAL CONDITION] and his [MEDICATION NAME]. R1 then picked up the pills, ingested them with water. TMA-A then returned to the medication cart where she unlocked the computer screen. TMA-A proceeded to document that she had administered R25's nebulized solution and R1's [MEDICATION NAME] and [MEDICATION NAME] tablets. She stated they were not supposed to document anything on the MAR until they were sure the resident had taken the medication. TMA-A stated this was how she had been trained. TMA-A did remove R1's medication cards from the cart for review and the label for the yellow tablets indicated the pills were [MEDICATION NAME] tablets 25-100mg give 2.5 tablets by mouth three times daily for [MEDICAL CONDITION] and the label for the white tablet indicated the card held [MEDICATION NAME] tablets 40mg give one tablet once a day for heart failure and localized [MEDICAL CONDITION]. The medications administered did match physician orders. According to an interview 12/12/19, 9:33 a.m. the director of nursing (DON) stated it was her expectation for nurses and TMAs to follow standard medication administration rights: checking the medication cards against the MAR to determine the right medication, the right dose, the right time and the right resident before giving the medications. DON stated she expected the medications to be checked against the MAR before being placed in the medication cup and again before returning the medications to storage. DON confirmed that simply reading a label without checking it against the MAR was not adequate to ensure a resident was receiving the correct medications and could result in a medication error. DON also confirmed placing unmarked medications in a pocket was against facility standards of medication administration. DON said the facility had recognized a problem with medication errors in the facility and had done audits and training with nurses and TMAs in response to that problem; however, DON stated she was unsure if they had standardized the use of their facility software for documentation in the MAR. DON confirmed that different staff may be using the software in different ways and they did not have any competency training specifically related to the Medication Administration software. The facility used PointClickCare's electronic medication administration software. A training video by the manufacturer, available to users in the facility, indicated the person administering medication should mark Y from the choice of Y/N (yes-administer or no-do not administer) for each medication being prepared for administration. After the medications had been compared to the MAR, the video indicated the person giving the medications should click on the yellow lock icon to hide the screen. After administration, the nurse or TMA would return to the computer program, re-open the screen to see the MAR and review the medications previously marked to ensure they were given. If they were not given the software allowed the user to change the Y to N but if no changes, the training indicated the user was simply to click on the save icon to document administration was complete. A policy on medication administration was requested and the facility provided a document titled Medication Administration dated 1/13/18. The policy indicated an objective of administer medication in an effective and safe manner, in accordance with physician's orders [REDACTED]. The procedure indicated the process was to check the name on the MAR matched the name on the medication label as well as the name of the medication, the dose, the route and the times to be given; in addition, this information was to be checked against the physician order [REDACTED]. Following medication administration the nurse or TMA should immediately document in the MAR. The current facility policy does not include any instruction on use of the facility software.

Based on observation, interview and record review the facility failed to assess a resident or obtain physician orders [REDACTED]. Findings include: R25's Admission Sheet indicated [DIAGNOSES REDACTED]. On 12/10/19 at 11:30 a.m. a trained medication aide (TMA-A) was observed to inform R25 that he was due for his nebulizer treatment and would give it to him as soon as he finished his meal. TMA-A then went to the medication cart and removed a package and placed it in her pocket. Shortly after, R25 finished his meal and TMA-A assisted him to his room. She removed the package from her pocket. The label of the package indicated the contents to be Ipratrobium-[MEDICATION NAME] Solution 0.5-2.5 MG/3Ml. TMA-A placed the nebulizer machine on R25's bed and stated he was able to turn it off when he was done if staff left the machine close enough to him. TMA-A filled the medication cup attached to a face mask with the medication solution and applied the mask to R25's face. TMA-A started the machine and said she would be back in about ten minutes and R25 told the TMA-A to make sure she didn't come back too soon. TMA-A stated R25 watched the clock like a hawk and wanted the treatment to run for exactly ten minutes. TMA-A then left R25's room, went to another resident's room and administered medications to that resident from items she had in her pocket and returned to her medication cart. At the medication cart, TMA-A stated it was her understanding that a person was allowed to self-medicate a nebulized solution if they were able to turn their machine off. She stated she did not think there was an assessment that needed to be done but thought there would be a spot in the Medication Administration Record [REDACTED]. TMA-A was unable to locate any direction in the MAR indicated [REDACTED]. TMA-A then stated the physician orders [REDACTED]. A registered nurse (RN-A) overheard TMA-A's statement and said, No, the order will say if someone CAN self-administer. RN-A instructed TMA-A that residents were not to self-administer medications until they had a physician's orders [REDACTED]. A review of R25's physician orders [REDACTED]. During an interview on 12/12/19, at 9:33 a.m. the director of nursing (DON) stated residents were not to be left unattended with their nebulizer solution running until they had been deemed competent to do so and had a physician's orders [REDACTED]. A policy related to self-administration of medications was requested. Facility provided a policy titled Self Medication Administration Policy dated 11/2008. The policy indicated that persons who express a desire to self-administer will have their cognitive, physical and visual ability to carry out this responsibility assessed. The policy also indicated an order would be obtained from the physician for self-administration of mediations. In addition, the policy indicated the information would appear on the resident's care plan and a quarterly review of the process would occur during care conference meetings.

Based on interview and document review, the facility failed to develop and/or have evidence of an in-effect transfer agreement with a local Medicare participating hospital entity. This had potential to affect all 37 residents in the facility who could require hospitalization on an emergent basis. Findings include: During the extended survey on 12/12/19, documention was requested from the administrator to demonstrate the facility had a transfer agreement in place with a local Medicare/Medicaid participating hospital entity. During interview on 12/12/19, at 1:27 p.m. the social services designee stated the facility did not have a transfer agreement with a hospital in place.

Based on observation and interview, the facility failed to ensure the air temperature was comfortable for 7 of 7 residents (R5, R7, R15, R18, R29, R30 & R34) reviewed for environmental concerns. This had the potential to affect all 44 residents in the facility. The findings include: On 11/13/18 at 1:11 p.m., R34 was observed sitting in resident room wearing a winter coat. R34 stated, It feels like it is too cold in here and the thermostat is set full bore. The thermostat in the resident's room was observed to be set at 88 degrees Fahrenheit. On 11/13/18 at 6:39 p.m., R5 was in observed in bed covered with blankets. R5 stated, My room is cold and the hall is even colder. During a random observation on 11/14/18 at 9:50 a.m., the surveyor was passing by R15's resident room. A staff member was overheard to state to R15, Well, I hope you warm up. A few moments later, R15 was observed to be sleeping in bed with numerous blankets piled on which were tucked around the resident's head with only a small portion of R15's showing. On 11/14/18 at 10:21 a.m., the speech language pathologist (SLP)-A was observed to bring R5 a second blanket from the blanket warmer due to her complaints of being cold in her room. SLP-A stated during interview on 11/15/18 at 12:09 p.m., (R5) consistently complains about being cold, in her room. SLP-A added, (R18) also complains of the cold and requests warm blankets all the time too. On 11/14/18 at 10:24 a.m., R34 was observed again to be wearing a winter jacket in his room. R34 stated, he wears it (the jacket) every day due to how cold it is. R34's wife was present and confirmed the room felt chilly. On 11/15/18 at 11:32 a.m., R7 was observed covered with blankets in bed and R30 was up in room wearing a sweat suit. Both R7 and R30 said their room was too cold and that they had complained of it to staff several times but nothing had been done. During an interview 11/15/18 at 12:21 p.m., activity assistant (AA)-A stated, We do have to get warm blankets for people, there's no specific time or place, but it seems there are always people who are cold. On 11/15/18 at 12:22 p.m., R29 was observed in the dining room with warm blankets provided by AA-A. R29 was also covered with a lap blanket and wore long sleeves. R29 stated she felt cold every day. During interview with nursing assistant (NA)-E on 11/15/18 at 12:26 p.m., nursing assistant (NA)-E verified residents complain of the cold and added, we go through a lot of warm blankets! NA-D, also present at that time, confirmed residents complain of the cold. When asked what was done about the cold NA-D stated, We grab them a warm blanket. When asked whether maintenance could take any action about the temperature, NA-D said, Oh, yeah, we can call him, he has his own line on the walkies. NA-D also explained there was a paper work order form staff could complete to notify maintenance of problems that occur after hours, and said if there was an emergency staff could reach the maintenance department via phone. On 11/15/18 at 11:32 a.m., the maintenance director (M)-A was asked about temperature readings in some of the resident rooms. M-A took temperature readings with the following results in Fahrenheit: RM #18A- 70.6 middle of room, and 72.5 by heat register RM #16A- 69.3 by heat register and 69 near the bed. M-A stated, The register is giving out heat but not much. RM #24B- 72.7 by register, 69.8 in middle of room and 71.3 by bed RM #8A- 67.8 near register, M-A confirmed by touch the register was not giving off much heat. The resident was observed in bed and the temperature near the bed was 68. Just outside RM#8 in the hallway, the temperature was 70.3. M-A said it was his goal to keep the facility temperature about 70-72 degrees. When asked about a process for knowing about heat issues, MA-A stated he would expect staff to provide a report that residents were uncomfortable. MA-A said, I don't know to fix it if they don't tell me. M-A verified he had not received any written requests to adjust the facility temperature. A copy of air temperature audits was requested but none were provided.

Based on observation, interview and document review, the facility failed to ensure timely repositioning/offloading in order to prevent and/or reduce the risk for pressure ulcer development for 1 of 3 residents (R20) reviewed for pressure ulcers. The findings include: R20's [DIAGNOSES REDACTED]. R20's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had severe cognitive impairment. The MDS also indicated R20 required extensive assistance of two staff members for transfers, and extensive assistance of one staff member for bed mobility and personal hygiene. The MDS further indicated R20 was frequently incontinent of bladder and bowel and was at risk for pressure ulcers. The MDS indicated R20 had a stage 2 pressure ulcer that had developed since the previous assessment and included the following interventions: pressure reducing device for chair and bed, pressure ulcer care, and applications of ointments/medications. The MDS did not indicate whether R20 had a turning or repositioning program. R20's pressure ulcer Care Area Assessment (CAA) dated 7/9/18, indicated R20 required help with mobility, was incontinent of bowel and bladder, had experienced cognitive and physical decline, and was able to move herself in bed but needed reminders to do so. The CAA indicated R20's other risk factors for pressure ulcers included: depression, severe [MEDICAL CONDITION] disease, terminal illness, and antidepressant medications. The CAA also indicated R20 required a special mattress or seat cushion to reduce or relieve pressure, and included: Will proceed to care plan to promote good skin care and avoid complications of decreased mobility and incontinence of bowel and bladder. A Sitting/Tissue Tolerance Evaluation dated 7/6/18, indicated R20 required assistance with repositioning every three hours however, handwriting on the form indicated R20 should be repositioned every 2.5-3 hours. R20's Lying/Tissue Tolerance Evaluation form dated 7/7/18, indicated R20 should be repositioned every three hours when lying. R20's skin care plan dated 7/19/18, indicated R20 was at risk for impaired skin integrity related to impaired mobility and bladder incontinence with a goal of: skin will be free of signs of skin breakdown related to pressure and incontinence. R20's transfer care plan dated 10/4/18, indicated R20 required assist of two staff with a walker and gait belt for pivot transfers, or use of the standing lift if R20 had increased weakness. The care plan further directed staff to reposition R20 every 2.5-3 hours and as needed while sitting, but indicated R20 often refused repositioning and directed staff to re-approach and notify the nurse if she continued to refuse. R20's Braden Scale (tool to evaluate pressure ulcer risk)/Comprehensive Skin Risk Data Collection dated 10/3/18, indicated R20 was at moderate risk for pressure ulcers and R20's mobility was very limited, which was defined as: makes occasional slight changes in body or extremity position but was unable to make frequent or significant changes independently. The evaluation section on the Braden Scale indicated R20 had a stage 2 pressure ulcer on the right side of the coccyx related to new wheelchair and indicated as a result, a new cushion had been implemented. The evaluation further indicated R20 should be toileted/transferred every 2.5-3 hours. R20's skin progress note dated 10/3/18, indicated a pressure area to the right side of R20's coccyx had remained closed with [MEDICATION NAME] tissue for four weeks with the implementation of intervention including: pressure reducing cushion, dietary supplement, repositioning schedule of every 2-3 hours, and good incontinence hygiene. During observation on 11/14/18 at 9:18 a.m., R20 was observed sitting in her wheelchair in the dining room with her eyes closed. R20's wheelchair was reclined approximately 30 degrees. A hospice nursing assistant (HNA)-A was sitting beside the resident and stated she had assisted R20 to the toilet with a standing lift around 8:30-8:45 a.m HNA-A said when she'd helped R20 to the toilet earlier, the resident had been incontinent of urine which was typical for her. At 9:40 a.m. on 11/14/18, R20 remained in seated in her wheelchair. R20 was leaning slightly forward and was eating her breakfast from a breakfast tray. At 9:47 a.m., R20 put her head down and closed her eyes. The wheelchair continued to be in the slightly reclined position. R20 remained in that position until 10:11 a.m. when the activity director (AD) asked her if she would like to go attend a communion service which R20 agreed to do. AD was observed to wheel R20 out of the dining room, but did not attempt or offer repositioning prior to taking R20 out of the dining room. At 10:50 a.m., R20 was wheeled back to the dining room and was parked next to a family member (FM). FM stated he had not attended the service, and R20 had been taken directly from the chapel back to the dining room. At 11:03 a.m., FM was observed to leave the dining room, and R20 continued to sit at the dining room table in the same reclined position. R20 remained in the dining room in the same position until 12:37 p.m. when NA-C wheeled R20 from the dining room to her room. At that time, NA-G adjusted R20's wheelchair to a 90 degree position. The two NAs then used a standing lift to stand R20, and pulled down her slacks and dry incontinent brief. R20 was cooperative. At that time, R20's right upper buttock was observed to have a pink area where the pressure ulcer had been and the lower right side of the pink area had a pinpoint open area. During an interview on 11/14/18, at 12:40 p.m., NA-C stated she had not previously noticed the small open area on R20's right buttock. NA-C stated she would write down the times she checked on/repositioned/toileted a resident on her care sheet, and when time allowed, she would add the documentation to the resident's electronic medical record (EMR). NA-C stated R20 had last been toileted by HNA-A at about 8:30 a.m. NA-C verified at 10:14 a.m. R20 had been in the chapel and after that had been in the dining room eating lunch so she had not offered/attempted to reposition or toilet R20. NA-C stated R20 was supposed to be repositioned every 2.5-3 hours, and confirmed R20 had not been repositioned/offloaded for a little over 4 hours. NA-C then added an EMR entry regarding toileting that reflected R20 had been toileted at 9:11 a.m. was incorrect because at 9:11 a.m., R20 had been leaning to her left side so she (NA-C) had boosted/shifted R20 to sit straight in the chair. NA-C also confirmed that position change would not have relieved pressure to R20's coccyx. During an observation on 11/14/18 at 12:45 p.m., NA-H entered R20's room, observed R20's bottom, confirmed the presence of the pinpoint opening on R20's right upper buttock, and stated she had not previously seen the pinpoint opening. During an interview and observation on 11/14/18 at 2:17 p.m., registered nurse (RN)-A stated a stage 2 pressure ulcer had closed a few weeks ago and further stated, once wounds were closed they were monitored for four weeks to ensure ongoing interventions were implemented to prevent the areas from re-opening. RN-A stated resident's repositioning/toileting schedules were expected to be implemented to prevent skin breakdown. RN-A stated the NAs should have worked around the activity program for R20 in order to offer toileting/repositioning cares. RN-A further added, if a resident refused, staff were supposed to re-approach the resident, and stated any continued refusals should be communicated to the nurse who would document the behavior. R20's progress note dated 11/14/18 at 6:13 p.m., indicated the resident had a small pin prick observed to the right side of the coccyx on the edge of scar tissue from a previous pressure injury. The progress note indicated Sensicare (a skin protectant cream), had been applied and the resident had been repositioned. During an interview and observation on 11/15/18, at 7:34 a.m. RN-A stated she had assessed R20's right buttock yesterday afternoon, and confirmed there had been a pinpoint opening. RN-A stated she had written her assessment on a piece of paper but had not yet entered the documentation into the EMR. At 7:58 a.m., RN-A observed R20's right upper buttock with the surveyor and the pinpoint open area was no longer visible. During an interview on 11/15/18 at 10:56 a.m., the director of nursing (DON) stated R20 should have been offloaded, off the area of pressure, for at least one full minute. The DON stated repositioning schedules were supposed to be implemented as identified in a resident's care plan, so R20 should have been repositioned/offered repositioning before or after the communion service in the chapel. The DON further stated shifting/boosting R20 would not have been enough to relieve pressure to the area, but reiterated pressure point areas would need to be offloaded for at least two minutes for tissue re-perfusion to occur. The facility's 2/2013 Skin Integrity policy included: Residents receive services to prevent impairment, if impairment is present services are designed to promote healing and prevent infection . Care Planning: a) Care plans are developed to address and minimize risks based on the comprehensive assessment. b) the plan of care focuses on services that maintain skin integrity, prevent pressure ulcers, and provide treatment as prescribed, based upon the underlying problem which caused the formation .Prevention: a) Residents whom are unable to reposition themselves, have a repositioning schedule implemented based upon the Tissue Tolerance assessment.

Based on observation, interview and document review, the facility failed to provide services to maintain range of motion (ROM) of extremities for 1 of 1 (R41) resident reviewed for ROM. The findings include: A Hospital Discharge Summary dated 7/25/18, indicated R41 was admitted to the facility after a fall at a previous living facility which resulted in a left [MEDICAL CONDITION]. The Discharge Summary also included: current functional status .exercises after [MEDICAL CONDITION] repair surgery: heel slides, active assisted hip flexion, active assisted hip abduction, ankle pumps, heel cord stretch, and upper extremity strengthening. Recommendations were documented on the Summary for R41 to have physical therapy evaluate and treat in the facility (nursing home). On 11/13/18 at 3:39 p.m., R41 was observed lying in bed in a semi-fowler's position (semi-seated with head and trunk elevated, in this case R41's trunk was elevated approximately 30 degrees). R41's hips were observed to be flexed and her legs were extended. R41 was observed to have some scissoring of her legs, with her left leg crossing the right, and her ankles were extended so her toes were pointed out, and her arms were flexed at elbows and pulled in toward the center of her torso. On 11/13/18 at 6:35 p.m., R41 was observed sitting in the dining area in semi-fowler's position in a Broda chair (a wheeled chair that allows a person to be tilted back). Again, R41's hips were flexed, her knees were slightly flexed, but her ankles were extended. R41 was observed to keep her arms pulled in towards her body. 11/14/18 at 9:44 a.m., R41 was observed during a sensory activity. R41 was in Broda chair with hips flexed, knees slightly flexed and arms pulled in towards body. At 10:30 a.m., R41 was observed to be taken to church positioned in the same manner. On 11/14/18 at 12:05 p.m., R41 was observed in the dining room, positioned in the same manner. On 11/14/18 at 3:14 p.m. R41 was observed in bed with her hips flexed and knees bent, turned on her right side without a pillow placed between knees to prevent her left hip from internal rotation. Arms pulled in toward center of body. When questioned about R41's ROM, nursing assistant (NA)-B was observed at that time to attempt to assist R41 with ROM. NA-B turned R41 onto her back and assisted the resident to raise her left arm upward at the shoulder joint. An audible pop could be heard and R41 grimaced. The resident's arm was extended straight out and could not go higher without discomfort. The NA-B was observed to lift R41's right arm, and was able to assist R41 to raise it above her head. During the observation, both elbows remained slightly flexed. At that time, lower extremity ROM was attempted, but R41 was stiff in the hip and knee joints and NA-B said she could not fully extend either joint. No further attempts were made due to R41 becoming resistive. On 11/15/18 at 7:17 a.m., R41 was observed in the dining area in a semi-fowler's position in her Broda chair. R41 was observed holding her left arm up with her right arm, elbows tucked in and right hand at chin level. Review of R41's record indicated R41 had been admitted to Hospice services on 8/27/18, and a significant change Minimum Data Set (MDS) assessment had been completed. The MDS dated [DATE], indicated R41 had limited ROM of lower extremities on one side. According to interview with registered nurse (RN)-A on 11/14/18 at 1:55 p.m., when asked if staff conducted ROM exercises with residents who had been admitted to hospice, RN-A stated R41 had not been assessed to have contractures, but that they would do ROM exercises if it was reported that R41 was developing them. RN-A stated she hadn't received any report of concerns. RN-B, the facility's MDS nurse, was interviewed on 11/14/18 at 2:43 p.m RN-B confirmed that R41 had limited range of motion on one side upon admission, and that according to the most recent MDS she continued to have limited ROM on one side. RN-B stated when a resident is unable to follow direction, such as R41, she talks to direct care staff to find out about the resident's level of mobility. RN-B further stated it was unlikely R41 would change much unless she would go downhill. When asked if staff assist R41 with ROM exercises to maintain her current functional status, RN-B said the nursing assistants will move her arms and legs during care, but RN-B was unsure whether that was recorded anywhere. RN-B also confirmed R41's care plan did not include an intervention for staff to perform ROM exercises. On 11/14/18 later in the afternoon, R41's care plan was noted to have been revised to include; gentle ROM as resident can tolerate. However, the resident's progress notes lacked any documentation regarding a current assessment of R41's ROM capabilities or limitations. During an interview on 11/14/18 at 3:43 p.m., certified occupational therapy assistant (COTA)-A stated R41 was demonstrating a decline in condition since admission. COTA-A furhter stated, A [MEDICAL CONDITION] would certainly reduce her ROM. COTA-A confirmed the therapy department had not sent a recommendation to nursing for ROM for R41. COTA-A also said therapy could work with residents to help set up a plan for ROM even if the resident was receiving hospice services. According to the Physical Therapy (PT) Plan of Care initiated 7/26/18, R41 had been referred to PT as she would benefit from continued therapy for strength, ROM, balance, transfers and gait to maximize functional mobility and safety. The notes indicated R41 had been discharged from PT on 8/26/18 to the care of hospice. A hospice nurse progress note dated 11/8/18, indicated R41 had the following problems: contracture, history of falls, limited range of motion and weakness. Further, the hospice standing orders indicated R41 could have a PT evaluation as needed. During an interview on 11/15/18 at 10:27 a.m., the director of nursing (DON) stated the MDS nurse might assess ROM by reading charting or by conducting interviews with the direct care staff. When asked if a nursing assistant could identify whether a person was getting contractures, the DON stated they could not. As to whether ROM exercises should be implemented for a resident, the DON said it was her expectation that a discussion regarding decreased mobility would occur during interdisciplinary team (IDT) meetings, and with the family. R41's progress notes were reviewed and failed to indicate whether ROM exercises had been discussed with the IDT or with the family. A facility policy related to assessment of range of motion or performance of range of motion was requested but not provided.

Based on interview and document review, the facility failed to update the staff posting when staffing changed. This had the potential to affect all 44 residents residing at the facility as well as family/visitors. Findings Include: Staff postings and schedules were reviewed from 10/12/18 to 11/15/18; no staff postings were updated, even when staffing changes occurred on the actual staffing. The Staffing posted 10/19/18, indicated for the day shift 66.25 hours for the number of assistants/techs. The daily unit assignments indicated for the day shift, one nursing assistant called in and the facility was working on finding a replacement. No changes had been made to reflect the actual hours worked on the Staff posting. The Staffing posted 11/6/18, indicated for the day shift 68 hours for the number of assistants/techs. The daily unit assignments indicated for the day shift, one trained medication aide (TMA) had called in and did not reflect the TMA hours had been covered. No changes had been made to reflect the actual hours worked on the Staff posting. On 11/15/18, at 12:05 p.m. the staff development coordinator verified the Staff postings did not reflect the changes made in staffing when the schedules were changed. On 11/15/18, at 12:53 p.m. the director of nursing (DON) stated, I was not aware the schedules that were posted should reflect the changes in staffing. The DON stated, we were not doing this but will start. The facility's undated Posting Direct Care Daily Staffing Numbers policy included: 3. Shift staffing information shall be recorded on the Daily Staffing Report. The information recorded on the form shall include .G. The actual time worked during that shift for each category and type of nursing staff.

Based on observation, interview and document review, the facility failed to ensure grooming needs (facial hair removal) was provided for 1 of 2 residents (R1) reviewed who were dependent upon staff assistance with activities of daily living (ADL). Findings Include: R1 was observed on 1/23/18, at 4:31 p.m. to be in the dining room sitting at a table in a wheelchair. R1 had four chins hairs on her chin that were visible and curled. R1 was observed on 1/24/18, 8:25 p.m. to be in the dining room being assisted to eat her breakfast by a staff member and the facial hairs on her chin remained. R1's admission record indicated R1 was admitted on [DATE]. R1's admission Minimum Data Set (MDS) an assessment dated [DATE], identified R1 required extensive assist of one for personal hygiene needs. R1's care plan with a print date of 1/17/18, included R1 required assist of one staff for personal hygiene. During an interview on 1/24/18, at 11:17 a.m. family member (FM)-A stated R1's appearance had always been important to her, and she would want facial hair to be removed. FM-A stated I just always did it for her (removed facial hair) so she would not be embarrassed after she was no longer able to do it for herself. During an interview on 1/24/18, at 1:56 p.m. nursing assistant (NA)-A stated she completed facial hair removal for residents during morning cares and stated it (facial hair removal) needed to be completed before they (the resident) come out of their room. During an interview on 1/24/18, at 2:01 p.m. nursing assistant (NA)-B stated she had gotten R1 ready for the day. NA-B stated she did not offer or attempt to remove any facial hair for R1 during her morning cares and stated she did not notice R1 to have any facial hair. NA-B Stated it was kind of a busy morning and I know that is not an excuse, but I did miss it. During an interview on 1/24/18, at 2:09 p.m. registered nurse (RN)-A verified R1's chin hairs through observation and stated she thought the chin hairs were approximately 0.7 centimeters (CM) long and stated R1 also had some (chain hairs) that were shorter. RN-A stated R1 was a new admission and family was supposed to bring in electric razors to be used. RN-A stated she expected the aides to notice the facial hair, report to their nurse so communication was done with family to bring in a razor. RN-A stated staff should be looking for facial hair daily with cares and verified R1 did not have a razor at the facility to use for facial hair removal. RN-A stated yes-facial hair was a dignity concern when asked. During an interview on 1/24/18, at 2:26 p.m. social services (SS)-A stated staff usually let me know when a resident was admitted and did not have a razor and I would contact the family to bring one in. SS-A stated staff must not have let me know R1 did not have a razor. SS-A stated she did not cover this upon admission with families. SS-A stated she expected staff to notice if a razor was needed to cut facial hairs. During an interview on 1/24/18, at 3:03 p.m. the director of nursing (DON) stated facial hair should be removed whenever they (staff) notice it and it should especially be looked at on bath days. The DON stated she expected staff to monitor facial hair during daily cares and shave residents if needed. The DON verified having facial hair was a dignity concern. The DON stated the facility did not have a policy or procedure for facial hair removal.

Based on observation, record review and interview, the facility failed to administer medication immediately after being set-up for 1 of 1 resident (R49) who was insulin dependent. This had the potential to affect residents who are insulin dependent. Findings included: R49 had two syringes of pre-drawn up insulin located in the medication cart on 12/6/16 at 5:17 p.m. This was found while completing a medication pass with Licensed practical nurse (LPN)-A. LPN-A was asked about the practice of pre-filling syringes before giving them to the resident. LPN-A verified that it was insulin pre-filled for R49. LPN-A was asked when she was going to complete the administration of the pre-filled insulin syringes. LPN-A stated, After supper, this is my normal routine (to set up the two doses together) because supper time is busy. LPN-A confirmed that the one syringe was Humalog for R49 to be given after supper was eaten and the second syringe was Lantus insulin to be given to R49 at bedtime. Physician orders [REDACTED].M.). During an interview with Registered Nurse (RN)-B on 12/7/16 at 12:54 p.m. concerning pre-filling of insulin prior to giving, stated, Not ok to preset medications up, not standard practice. During an interview with the Director of Nursing (DON) on 12/7/16 at 1:01 p.m., she said that the expectation is to administer medication right away after set up. During phone interview with the facility consulting pharmacist on 12/08/16 at 11:34 a.m. it was their expectation to not draw up insulin medication until just prior to giving to resident. Policy entitled Medication Administration revised 3/16 reads under Administration Requirements: are to distribute the medication to the resident in a timely manner.

Based on interview and document review the facility failed to accurately code a quarterly Minimum Data Set (MDS) for 1 of 3 residents (R1) reviewed for activities of daily living (ADLs). Findings Include: R1's Minimum Data Set (MDS) quarterly assessment dated [DATE], identified R1 required extensive assistance of two staff members for toileting. R1's Minimum Data Set (MDS) quarterly assessment dated [DATE], identified R1 was totally total dependent on staff for toileting. R1 was observed during cares on 12/06/2016, at 3:28 p.m., two staff members checked R1 for incontinence of bowel movement and repositioned her in the bed. R1 was observed to be totally dependent on staff for toileting and repositioning. On 12/06/2016, at 3:15 p.m. nursing assistant (NA)-A stated R1 required total assistance for toileting. On 12/07/2016, at 10:59 a.m. registered nurse (RN)-A stated R1 was checked and changed for toileting. RN-A stated R1 should have been coded as total assistance for toileting on the quarterly MDS dated [DATE].

Based on observation, interview and document review, the facility failed to ensure a self- administration of medication assessment was completed for 1 of 1 resident (R30) observed to have self-administer a nebulizer treatment. Findings include: R30's Admission Record, dated 10/19/16, indicated R30 was diagnosed with [REDACTED]. R30's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R30 was severely impaired and required extensive assistance with bed mobility, transfers, dressing and toileting, personal hygiene, walking in her room and in the corridor, and was independent with eating. R30's physician's orders [REDACTED]. On 12/6/16, at 4:02 p.m. Licensed Practical Nurse (LPN)-A was observed to set up nebulizer for R30. After setting up and stating the nebulizer treatment LPN-A left R30 alone in her room seated in her recliner. On asking LPN-A when she returned minutes later, LPN-A stated she was going to get another nebulizer for another resident then come back. LPN-A was asked if R30 has a self-administration order. LPN-A stated she was unaware of whether she has one or not. Document review found no assessment for R30 to self-administer medication. On 12/06/16, at 4:28 p.m. LPN-A stated that it was her normal routine for R30, to set up, leave and come back in ten minutes when giving the nebulizer treatment. On 12/7/16 1:41 p.m. Director of Nursing (DON) interviewed and verified that there was no order for self-administration of medication when LPN-A administered nebulizer to R30. After inquiring about the self administration assessment the DON gave the surveyor a newly completed document at 4:02 p.m. the DON provided a document entitled Medication/Nebulizer Self Admin. Safety Screen effective date 12/7/16 at 9:18 a.m. and Physician's Telephone Orders signed by attending physician 12/7/16.

Based on interview and record review, the facility failed to provide the necessary services to ensure the safety of residents related to a known water temperature hazard (upon initial discovery of this hazard) for 1 of 2 residents (R1) reviewed for burn injuries. R1 sustained multiple lower extremity second [MEDICAL CONDITION] required emergency room (ER) evaluation and hospitalization . Findings include: Review of the facility's vulnerable adult policies, dated 2012, indicated the facility will not condone any form of resident neglect and included a sign of neglect to be inadequate provision of care. These policies also included a procedure for identifying and monitoring areas within the facility that may make neglect more likely to occur. The facility's undated policy titled, Adjusting Water Temperature In Resident Rooms And Shower/Tub Rooms, included documentation that the hot water temperature is not to exceed 112 degrees Fahrenheit (F), and in the event it does, the procedure for testing of water temperatures should be followed. On 03/14/2013 at 1:53 p.m., the facility Administrator submitted a copy of a facility form titled Emergency Contact Numbers, which contains the cell phone number for maintenance director-B and additional external contractor phone numbers for facility water problems. The Administrator stated this form is located in three separate places on the walls of the nursing office and in the staffing book. The Administrator stated staff would use the emergency contact numbers for urgent safety issues. Review of the Field Crest Care Center Resident Incident Report for R1 dated 03/11/2013 showed nursing assistant (NA)-H was going to give R1 a bath, the water was hot, NA-H tried to add cold water and the water was not cold; R1's lower extremities were immersed in water causing scalding burn to R1's bilateral lower extremities before NA-H could get R1 out of the tub. Record review for R1 revealed a Diseases Index Report that included [DIAGNOSES REDACTED]. Review of R1's hospital Dismissal Summary report dated 03/16/2013, submitted by the facility on 03/20/2013, contained documentation that R1 sustained bilateral lower extremity second degree burns. This report also contained documentation that R1's medical history included [MEDICAL CONDITION] (numbness and pain resulting from nerve damage), related to R1's condition of diabetes, which has resulted in a decreased sensation of feeling in R1's lower extremities. When interviewed on 03/14/2013 at 10:45 a.m., NA-C indicated that she initially discovered problems with the water temperature in the wing 2 tub room the morning of 03/10/2013 (the day prior to R1's burn injuries). NA-C stated the hot water temperature was 130 degrees (F) and when NA-C attempted to add cold water to the tub, the water turned completely off. Prior to completing any resident baths that day, NA-C stated she reported this problem to licensed practical nurse (LPN)-D and LPN-L. NA-C did not use the wing 2 tub room for resident bathing on 03/10/2013, and, instead, used the wing 3 tub room for tub baths. NA-C took no further action in regards to this problem. When interviewed on 03/14/2013 at 11:10 a.m., LPN-D verbalized awareness on Sunday (03/10/2013) that NA-C mentioned something regarding problems with the water temperature in the wing 2 tub room. LPN-D took no further action in response to NA-C's report of water temperature problems because "there wasn't a problem" as NA-C continued with resident baths. LPN-L was not available during the investigator's onsite visit. When interviewed on 03/14/2013 at 1:17 p.m., NA-F verified that on Sunday morning (03/10/2013), right at the start of the shift, NA-F heard NA-C reporting to nursing staff that there was no cold water in the wing 2 tub room. NA-F took no further action regarding this information. When interviewed on 03/15/2013 at 2:21 p.m., NA-H stated the tub in the wing 2 tub room was used for R1's bath the morning of 3/11/2013 and NA-H denied any awareness of water temperature problems prior to assisting R1 into the tub. When interviewed on 03/14/2013 at 8:30 a.m., maintenance director-B indicated first becoming aware of the water temperature problem on 03/11/2013, after R1's incident with the hot water temperature. Maintenance director-B indicated once he was informed of this problem, he immediately went to the wing 2 tub room and noticed the tub water temperature went up high when the cold water was turned on to mix with the 117 degree (Fahrenheit (F)) hot water temperature. The cold water line showed a 121 degree F temperature reading and it should have been around 56 to 60 degrees F. Additionally, the facility's policy titled Skin Integrity, last revised 08/2012, indicated that maintaining the skin integrity of the residents is a priority for the provision of services. This policy contained a procedure for direct care staff to inform the charge nurse of any skin problems noted during care. When interviewed on 03/14/2013 at 11:47 a.m., NA-E stated the NAs called for a nurse and the nurse indicated she was not available at the time as she was busy passing medications. NA-E stated R1's feet were red but not blistering and since there were no signs of R1 being burnt, the NAs went ahead and took R1 to the wing 3 tub room (to finish giving R1 a bath). When interviewed on 03/15/2013 at 2:21 p.m., NA-H stated NA-E tried to contact a nurse and was not able to do so. NA-H verified that the nurse did not check R1's feet prior to transferring R1 from the wing 2 tub room to the wing 3 tub room.

Based on interview, record review and observation, the facility failed to evaluate a known water temperature hazard and failed to implement interventions to reduce any possible risk of resident injury related to this known water temperature hazard for 1 of 2 residents (R1) reviewed for burn injuries. R1 sustained multiple bilateral lower extremity second degree burns that required emergency room (ER) evaluation and hospitalization . Findings include: The facility's undated policy titled, Adjusting Water Temperature In Resident Rooms And Shower/Tub Rooms, indicated that the hot water temperature is not to exceed 112 degrees Fahrenheit (F), and in the event it does, the procedure for testing of water temperatures should be followed. This procedure included specific instructions for testing water temperature with the use of a hand held thermometer (however, the first procedure for testing temperatures in the tub included instructions to turn on the hot water in the resident's bathroom sink, not the tub). Record review for R1 revealed a Diseases Index Report that included [DIAGNOSES REDACTED]. Review of R1's hospital Dismissal Summary report dated 03/16/2013, submitted by the facility on 03/20/2013, contained documentation that R1's medical history included peripheral neuropathy (numbness and pain resulting from nerve damage), related to R1's condition of diabetes, which has resulted in a decreased sensation of feeling in R1's lower extremities. An Interdisciplinary Note for R1 entered on 03/11/2013 at 7:50 a.m. included the following documentation: "resident sustained [REDACTED]."-..." An additional Interdisciplinary Note for R1 entered on 03/11/2013 at 11:12 a.m. included the following documentation: "...Noted 2nd degree burns to almost entire surface of (left) foot and possible 3rd degree burns to great toe where toenail had been previously removed per podiatrist. Large blister to back of (right lower extremity)..." Review of the Field Crest Care Center Resident Incident Report for R1 dated 03/11/2013 showed nursing assistant (NA)-H was going to give R1 a bath, the water was hot, NA-H tried to add cold water and the water was not cold; R1's lower extremities were immersed in water causing scalding burn to R1's bilateral lower extremities before NA-H could get R1 out of the tub. R1's left lower extremity was red in color 3/4 of the way down R1's shin to all of R1's foot with skin peeling and R1's right foot also exhibited peeling skin when NA-H started drying R1's foot. This incident report also included the following documentation of R1's injuries: left heel oozing serous (drainage), left lower extremity 1 centimeter (cm) blister starting to form 2 inches above R1's ankle, left lateral great toe with a 2 1/2 inch skin tear with blister formation in between great toe and 2nd (toe), 1 x 2 inch skin tear to left foot and a 2 cm diameter skin tear to outer left foot. Additional documentation of R1's injuries showed the left foot with a 2nd degree burn, a 1st degree burn from the left ankle to the left mid calf and a 2nd degree burn to the right shin. Review of R1's physician's orders [REDACTED]. R1's Patient Transfer Form-Nursing Home To Hospital, signed by RN-A on 03/11/2013, contained documentation that R1 was transferred to the ER for evaluation of burns to the bilateral lower extremities. When interviewed on 03/14/2013 at 7:50 a.m., RN-A verified R1 was not in the facility at the time of the investigator's onsite visit (03/14/2013) and had not yet been discharged from the hospitalization of 03/11/2013. RN-A stated R1 was getting a bath, R1 told NA-H the water was too hot and NA-H attempted to add cold water, which also came out hot. When interviewed on 03/14/2013 at 10:45 a.m., NA-C indicated that problems with the water temperature in the wing 2 tub room were first noted the morning of 03/10/2013 (the day prior to R1's burn injuries). NA-C stated the hot water temperature was 130 degrees F and when NA-C attempted to add cold water to the tub, the water turned completely off. Prior to completing any resident baths that day, NA-C stated she reported this problem to licensed practical nurse (LPN)-D and LPN-L. NA-C did not use the wing 2 tub for resident bathing and used the wing 3 tub room to complete resident tub baths on 03/10/2013. NA-C took no further action regarding this problem. NA-C verbalized unawareness of R1 having a loss of sensation in R1's lower extremities. When interviewed on 03/14/2013 at 1:17 p.m., NA-F stated on Sunday morning (03/10/2013), right at the start of the shift, while in the dining room, NA-C reported to LPN-D that there was no cold water in the wing 2 tub room. NA-F indicated nothing further was done regarding the information from NA-C and NA-F thought LPN-D would contact facility maintenance regarding this problem. NA-F also indicated she did not communicate this information to any other staff. NA-F added that R1 stated (R1) got burnt in the tub, R1 replied "ya" when asked if R1 had pain and R1's legs were shaking while in bed (following the incident). NA-F was aware the tub contained a temperature gauge, but was not able to verbalize the maximum safe hot water temperature established by the facility. Review of R1's Medication Administration Record for March 2013 contained documentation that indicated R1 received R1's routine dose of extra strength tylenol scheduled for 6 a.m. on 03/11/2013 (routinely scheduled for left extremity pain). When interviewed on 03/14/2013 at 11:10 a.m., LPN-D stated NA-C mentioned something on Sunday (03/10/2013) during a meal time, regarding problems with the water temperature in the wing 2 tub room. LPN-D could not remember any further specific details regarding what NA-C reported. LPN-D replied "No" that she did not do anything in response to NA-C's report of water temperature problems. LPN-D stated the reason no further action was taken was because "there wasn't a problem" as NA-C continued with resident baths. LPN-D replied "I don't even know" when asked about the facility's safe hot water temperature range for resident bath tubs; LPN-D added "I have not participated in any of the bath tub training or even given a bath here." LPN-D indicated R1 did not complain of peripheral neuropathy and stated "I would think (R1) would be able to tell you if the water was hot." LPN-L was not available during the investigator's onsite visit. When interviewed on 03/14/2013 at 11:47 a.m., NA-E stated she assisted NA-H in transferring R1 into the tub in wing 2 tub room on 03/11/2013. During this time, NA-E denied any awareness of any water temperature problems. R1 stated the tub water was warm as R1's left foot was placed in the tub water and R1 replied "no" when asked if it was too warm. As R1's right foot entered the tub water, R1 stated "it's hot, it's hot, it's hot!" NA-H attempted to add cold water and as water was added, R1 continued to say "it's hot." NA-E stated the cold water never got cold and the tub water temperature gauge showed a water temperature reading of around 128 to 129 degrees F. After R1 was removed from the tub, NA-E stated R1's feet were red. NA-E could not verbalize the maximum safe hot water temperature established by the facility and NA-E also indicated NA-E had never been trained on checking water temperatures. When interviewed on 03/15/2013 at 2:21 p.m., NA-H stated R1 was the first resident to receive a tub bath the morning of 03/11/2013. NA-H prepared the tub in the wing 2 tub room for R1's bath and the tub water temperature gauge showed a reading of approximately 92 to 93 degrees F. NA-H denied any awareness of water temperature problems during this time. NA-H and NA-E transferred R1 into the tub; the tub was 1/4 full of water and it covered R1's feet and calves. NA-H stated when she lowered R1 into the tub water, R1 stated the water was too hot. NA-H turned on the cold water and NA-H stated "that's when I realized the cold water was not working." NA-H opened up the tub drain right away to drain the tub water and held R1's right foot up out of the water. NA-H and NA-E assisted R1 out of the tub as quickly as possible. R1's feet appeared "a little pink" and R1's left toe was bleeding a bit (NA-H stated R1 recently had this toenail removed and the bleeding has occurred before like this). NA-H informed NA-F not to let anyone use the wing 2 tub room and NA-F commented that there were problems with wing 2 tub room the day before. NA-H proceeded to assist R1 to the wing 3 tub room and completed R1's bath without any further problems. NA-H stated she filled the wing 3 tub with water colder than lukewarm temperature and indicated the water temperature was 78 degrees F. After the bath, NA-H noticed R1 had peeling skin when NA-H dried R1's feet. NA-H requested immediate assistance from the nurse, LPN-L responded and LPN-L provided initial first aide treatment to R1. NA-H verbalized an unawareness of R1's decreased sensation of feeling in the lower legs and also could not verbalize the maximum safe hot water temperature established by the facility. On 03/14/2013 at 1:53 p.m., the facility Administrator submitted a copy of a facility form titled Emergency Contact Numbers, which contains the cell phone number for maintenance director-B and additional external contractor phone numbers for facility water problems. The Administrator stated this form is located in three separate places on the walls of the nursing office and in the staffing book. The Administrator stated staff would use the emergency contact numbers for urgent safety issues. When interviewed on 03/14/2013 at 8:30 a.m., maintenance director-B indicated first becoming aware of the water temperature problem on 03/11/2013, after R1's incident with the hot water temperature. Maintenance director-B indicated once he was informed of this problem, he immediately went to the wing 2 tub room and noticed the tub water temperature went up high when the cold water was turned on to mix with the 117 degree (F) hot water temperature. The cold water line showed a 121 degree F temperature reading and it should have been around 56 to 60 degrees F. Maintenance director-B stated that he notified an external contractor to investigate the problem. Review of an email dated 03/14/2013, from this external contractor and addressed to the facility's Director of Nursing (DON), showed the problem consisted of high temperature (140 degrees F) water, back-feeding to the cold water supply line. On 03/14/2013 at 12:44 p.m., the investigator accompanied maintenance director-B during temperature checks of the hot water in the facility. Observations verified accuracy of water temperature readings displayed on the bath tub temperature gauge in the wing 2 tub room (the bath tub temperature gauge, maintenance director-B's thermometer and the investigator's thermometer showed hot water temperature readings within approximately one degree of each other). When interviewed on 03/14/2013 at 3:11 p.m., the DON indicated she first knew of the water temperature problem on 03/11/2013, at approximately 7:50 a.m., when she was notified via phone of the burn injuries sustained by R1. The DON stated on 03/11/2013 that hot water was also coming into the toilets when flushed. The DON was not aware until 03/14/2013 (the date of the investigator's onsite visit) that staff initially discovered problems with the water temperature on Sunday, 03/10/2013. The DON also knew of R1's condition of peripheral neuropathy prior to this incident. Review of R1's hospital Dismissal Summary report dated 03/16/2013, submitted by the facility on 03/20/2013, contained documentation that R1 sustained bilateral lower extremity second degree burns. R1 was discharged back to the facility on [DATE], with orders for pain management and continued treatment of [REDACTED]. Additionally, during an observation on 03/14/2013 at 9:28 a.m., NA-C assisted a resident with a shower in the wing 3 shower room. NA-C indicated staff are not able to tell what the water temperature is during showers, as the shower does not have a water temperature gauge with a digital read-out like the tubs. NA-C relies on the resident to verbalize when the water gets too warm. During the shower, a temperature gauge on the wall adjacent to the shower head showed movement of the gauge needle when the NA-C adjusted the water temperature handle to the shower. On 03/14/2013 at 12:57 p.m., maintenance director-B accompanied the investigator to the wing 3 shower room. Observations verified accuracy of water temperature readings displayed on the wall temperature gauge and the hand-held thermometers that maintenance director-B placed into the water coming out of the shower head; maintenance director-B stated "this one definitely worked" when referring to the water temperature gauge on the wall adjacent to this shower head.